Information

About Your

Enrollment and Benefits

Report public assistance fraud by calling 877-865-3432 (toll free) or visiting www.reportfraud.wisconsin.gov. You may remain anonymous.

If you have a disability and need this information in a different format, need it translated to another language, or have any questions about your rights and responsibilities, contact your agency or call Member Services at 800-362-3002. All language services are free of charge.

To get the address or phone number of your agency, go to www.dhs.wisconsin.gov/forwardhealth/resources.htm or call 800 - 362 - 3002 .

The information concerning the health care programs provided in this Handbook is published in accordance with: Titles XI, XIX and XXI of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.

The information concerning the FoodShare program provided in this Handbook is pursuant to chapter 15 of title 44, United States Code, Federal Register Title 7 Subtitle B Chapter II Subchapter C.

The information concerning the FoodShare Employment and Training program provided in this Handbook is pursuant to chapter 15 of title 44, United States Code, Federal Register Title 7 Subtitle B Chapter II Subchapter C; andChapter 49 of the Wisconsin Statutes.

The information concerning the Caretaker Supplement program provided in this Handbook is published in accordance with Section 49.775 of the Wisconsin Statutes and Chapter HA 3 of the Wisconsin Administrative Code.

Your Connection to Health Care Coverage and Nutrition

Benefits

Enrollment and BenefitsNovember 2019

Table of Contents

KEY CONTACTS..............................................................1

OVERPAYMENTS, FRAUD, AND INTENTIONAL PROGRAM VIOLATIONS 3

FoodShare Overpayments........................................................3

FoodShare Fraud......................................................................3

FoodShare Intentional Program Violation.................................3

Health Care Overpayments.......................................................4

Health Care Fraud....................................................................4

GENERAL PROGRAM INFORMATION......................5

Do You Have Questions?..........................................................5

Program Income and Asset Limits.............................................5

ACCESS.....................................................................................5

ForwardHealth.........................................................................5

Nutrition Assistance.................................................................5

FoodShare Wisconsin..........................................................5

Health Care..............................................................................5

BadgerCare Plus..................................................................5

BadgerCare Plus Prenatal Plan............................................5

Plans for People Who Are Elderly, Blind or Disabled...........5

Limited Coverage Plans.......................................................5

Who Can Enroll?.......................................................................6

FoodShare Wisconsin...............................................................6

BadgerCare Plus.......................................................................6

BadgerCare Plus Prenatal Plan.................................................6

Wisconsin Medicaid for the Elderly, Blind or Disabled (EBD). . .6

Wisconsin Well Woman Medicaid............................................6

Help From Others.....................................................................7

Legal Guardian, Power of Attorney, and Conservator..............7

Authorized Representative.......................................................7

NUTRITION ASSISTANCE............................................8

FoodShare Wisconsin...............................................................8

How to Apply............................................................................8

Priority FoodShare Services......................................................8

Work Requirement for Able-Bodied Adults Ages 18 Through 49 8

Work Registration Requirement for Applicants and Members Ages 16 Through 59 9

Work Registration Requirement Sanction................................9

FoodShare Employment and Training (FSET) Program...........10

How Your FoodShare Benefits Are Calculated........................10

Household Income.............................................................10

Income Credits..................................................................10

Other Credits.....................................................................10

Examples of How Income and Credits are Calculated........11

Wisconsin QUEST Card...........................................................12

When You Get Your Benefits.............................................12

Spending Your Benefits.....................................................13

Authorized Buyers.............................................................13

Account Balance................................................................14

Selecting a Personal Identification Number (PIN)..............14

Keep Your PIN Safe............................................................15

If You Forget Your PIN.......................................................15

Problems With Your QUEST Card......................................15

Error Messages..................................................................15

Taking Care of Your QUEST Card.......................................15

If Your Card Is Lost or Stolen.............................................16

If Your Card Is Damaged....................................................16

Monitoring of Excessive Replacement QUEST Cards.........16

Using Your Card.................................................................16

Store Adjustments.............................................................17

Returning a Purchase.........................................................17

If You Move.......................................................................17

Keep Your QUEST Card......................................................17

FoodShare Rules and Responsibilities....................................17

Overpayments...................................................................17

Quality Control Review......................................................17

Reporting Changes............................................................17

FoodShare Six-Month Reporting.......................................18

Renewals...........................................................................18

FULL COVERAGE HEALTH CARE PLANS..............19

BadgerCare Plus.....................................................................19

How to Apply..........................................................................19

Enrollment Date.....................................................................19

Income Rules and Limits.........................................................19

How Income Is Counted....................................................19

Who Is Included in Your Group..........................................19

How Income Is Counted.........................................................21

Exceptions: Income...........................................................21

Types of Income That Are Counted...................................21

Income Deductions and Disregards...................................22

Income Disregards.............................................................24

Medicaid for the Elderly, Blind or Disabled.............................24

How to Apply..........................................................................24

Enrollment Date.....................................................................25

Income Credits.......................................................................25

Program Income and Asset Limits..........................................27

Assets................................................................................27

Medicaid Standard Plan.........................................................28

Asset Limit.........................................................................28

Income Test.......................................................................28

Medicaid Purchase Plan....................................................29

Long-Term Care Services........................................................29

Asset Limit.........................................................................30

Income Test.......................................................................30

Institutional Medicaid........................................................30

Home and Community-Based Waivers..............................31

Family Care........................................................................32

Family Care Partnership....................................................32

Spousal Impoverishment Protections................................32

Divestment........................................................................34

ForwardHealth Card...............................................................34

LIMITED COVERAGE HEALTH CARE PLANS.......36

Family Planning Only Services.................................................36

Medicare Savings Program.....................................................36

Qualified Medicare Beneficiary (QMB)...................................37

Specified Low-Income Medicare Beneficiary..........................37

Specified Low-Income Medicare Beneficiary Plus..................37

Qualified Disabled and Working Individual............................37

When Your Payments Will Begin............................................37

Medicare Savings Program Calculations.................................37

SeniorCare Prescription Drug Assistance Program...................37

Coverage Levels......................................................................38

SeniorCare Card.....................................................................38

Tuberculosis-Related Services Only.........................................38

Emergency Services Plan........................................................38

IMPORTANT INFORMATION FOR ALL HEALTH CARE PLANS 39

Deductible Plans.....................................................................39

Limits for Emergency Services.................................................39

Prior Authorization for Services..............................................39

If You Get a Bill.......................................................................39

Enrollment in a BadgerCare Plus or Medicaid Health Maintenance Organization (HMO) 40

Enrolling in an HMO...............................................................40

Benefits of an HMO................................................................40

Better Access to Care.........................................................40

Personalized and Coordinated Care..................................40

Increased Quality...............................................................40

Member Safeguards..........................................................40

Other Providers......................................................................41

Report Your Changes..............................................................41

BadgerCare Plus and Medicaid...............................................41

Family Planning Only Services................................................41

Well Woman Medicaid...........................................................41

How to Report Changes.........................................................42

Renew Your Benefits..............................................................42

Monthly Premiums.................................................................42

BadgerCare Plus Premiums and Copays.................................42

Premium Payment Methods..................................................42

Nonpayment of Premiums.....................................................42

Other Health Insurance..........................................................43

Access to Affordable Employer-Sponsored Health Insurance 43

Applying for BadgerCare Plus for Pregnant Women................44

BadgerCare Plus Prenatal Services.........................................44

Accident and Injury Claims.....................................................44

Required Proof/Verification for FoodShare and Health Care. . .44

COLLECTION AND USE OF INFORMATION.........45

NON-EMERGENCY MEDICAL TRANSPORTATION46

Mileage Reimbursement (Gas Payment).................................46

Meals and Lodging.................................................................46

Schedule a Ride......................................................................46

OTHER PROGRAMS....................................................48

Caretaker Supplement............................................................48

WIC (Women, Infants, and Children Program).........................48

Job Center of Wisconsin.........................................................48

YOUR RIGHTS..............................................................49

Fair Hearings..........................................................................49

Prehearing Conference..........................................................49

Fair Hearing............................................................................49

When to Use the Fair Hearing Process...................................49

How to Ask for a Fair Hearing.................................................50

Preparing for a Fair Hearing...................................................50

Continuation of Benefits........................................................50

Effects of the Fair Hearing......................................................50

Rehearing...............................................................................51

Appealing a Hearing or Rehearing Decision...........................51

Legal Help..............................................................................51

Letters About Your Benefits....................................................51

NONDISCRIMINATION..............................................52

Nondiscrimination Notice.......................................................52

USDA Nondiscrimination Statement.......................................53

APPENDIX A: PROGRAM INCOME LIMITS...........54

APPENDIX B: COVERED SERVICES AND COPAYS FOR BADGERCARE PLUS AND MEDICAID PROGRAMS......................................................................................... 55

Covered Services and Copays..................................................55

Out-of-State Claims................................................................55

Emergencies......................................................................55

Nonemergencies...............................................................55

Services Not Covered Under Any Plan.....................................56

HealthCheck...........................................................................56

Table of Covered Services and Copays....................................57

APPENDIX C: BADGERCARE PLUS AND MEDICAID PURCHASE PLAN MONTHLY PREMIUMS 59

Paying Your Premium.............................................................59

Children..................................................................................59

Monthly Premium Tables.......................................................60

Enrollment Information..........................................................60

APPENDIX D: EXAMPLES OF PROOF....................62

Resources and Contact Information

All Applicants and MembersUse the ACCESS Website (access.wisconsin.gov) to: See what health, nutrition, and other support

programs you may be able to get. Apply for BadgerCare Plus, Medicaid, or

FoodShare. Check to see what your benefits are (for example,

the health care plan you are enrolled in or the amount of your FoodShare benefits).

Check the status of your benefits. Report changes (for example, a change in address, a

job, or health care). Renew your benefits or see when your renewal is

due for health care or FoodShare. Submit a FoodShare Six-Month Report form. Replace your lost, stolen, or damaged

ForwardHealth card. Get an Explanation of Medical Benefits. Check to see what HMO you are enrolled in. Choose to share your email address with our health

care partners (for example, your HMO). Choose to get your letters online instead of by

regular mail, or update your email address.

Use the MyACCESS Mobile App to: See the programs you’ve applied for or are enrolled

in. Get reminders of actions you need to take or

documents you need to submit. Submit and track documents.

To download the app, go to the App Store or Google Play, and search for “MyACCESS Wisconsin.”

Contact Your Local Agency to: Ask questions about enrollment rules for

BadgerCare Plus, Medicaid, or FoodShare. Complete your FoodShare interview. Find out why your application was approved or

denied. Find out why your benefits have been reduced or

ended. Find out about premiums owed and where to send

payment. Report changes to your information (if you prefer to

do this by phone).

Send proof/verification.

To get the address and phone number of your agency, go to www.dhs.wisconsin.gov/forwardhealth/imagency/index.htm or call 800-362-3002.

Medicaid and BadgerCare Plus MembersCall 800-362-3002 to: Ask questions about covered services and copays. Ask questions about enrollment rules. Find a provider. Replace your lost, stolen, or damaged

ForwardHealth card.

FoodShare MembersCall QUEST Card Service at 877-415-5164 to: Get general information about your QUEST card. Report that you did not get a QUEST card. Report a lost, stolen, or damaged QUEST card. Get your current account balance.

Note: Other websites or mobile apps may offer to provide your FoodShare balance and account activity. We recommend only using the ebtEDGE website and mobile app to view your FoodShare balance and account activity as other websites or mobile apps may pose security risks.

Use the ebtEDGE Website (ebtedge.com) to: Check your current account balance. View account activity.

Use the ebtEDGE Mobile App to: View your current FoodShare balance. View FoodShare activity from the last 60 days,

including detailed information about recent purchases.

Find retailers near you that accept the QUEST card.

To download the app, go to the App Store or Google Play, and search for “ebtEDGE.”

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SeniorCare MembersCall the SeniorCare Customer Service hotline at 800-657-2038 to: Ask questions about the use of your SeniorCare card. Ask questions about your SeniorCare enrollment or

level of enrollment. Ask questions about your out-of-pocket costs or

copays. Ask questions about covered drugs. Replace your lost, stolen, or damaged SeniorCare

card. Report that the name on your card is wrong.

Members Needing Non-Emergency Medical TransportationContact MTM, Inc., to: Schedule a ride: 866-907-1493 (voice) or 711

(TTY). Find out where your ride is: 866-907-1494. File a complaint: 866-436-0457.

Members Enrolled in an HMO (Health Maintenance Organization) To contact an HMO enrollment specialist, call

800-291-2002. To contact an HMO ombudsman, call 800-760-0001. To report a problem with your HMO, contact your

HMO and ask to speak with a member advocate. To find out which HMO you are enrolled in, call

800-362-3002.

To Mail or Fax Applications and/or Proof/Verifications/ChangesIf you live in Milwaukee County, use the following address:

Milwaukee Document Processing Unit (MDPU)PO Box 05676Milwaukee, WI 53205

Or fax to 888-409-1979

If you do not live in Milwaukee County, use the following address:

Central Document Processing Unit (CDPU)PO Box 5234Janesville, WI 53547-5234

Or fax to 855-293-1822

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Overpayments, Fraud, and Intentional Program Violations

NOTE: Everyone who is enrolled in any of the programs listed in this handbook is responsible for following all program rules.

Fraud means getting benefits or assistance you know you should not get or helping someone else get benefits or assistance you know that person and household should not get. Anyone who commits fraud can be prosecuted. If an agency decides that a person and household got health care or FoodShare benefits by committing fraud, they will require that person and responsible individuals to pay back the state for those benefits, in addition to other penalties.

To report public assistance fraud at the state level, call 877-865-3432 (toll free) or visit www.reportfraud.wisconsin.gov. You may remain anonymous.

To report fraud at the federal level, call 800-424-9121 or visit www.usda.gov/oig/hotline.htm.

FoodShare OverpaymentsOverpayments are benefits you received but should not have. You must repay benefits you received in error, even if it is the agency’s fault and not your own. All adults or emancipated minors who were included in a food unit, or should have been included at the time the overpayment occurred, are responsible for the repayment of the overpaid benefits. If responsible members move to another food unit, they are still responsible for the overpayment. Individuals are responsible for 100 percent of the overpayment until it is repaid in full. An authorized representative may also be held responsible for overpayments if he or she intentionally violates program rules.

FoodShare FraudIf any information you give is found to be incorrect, you may be denied benefits and/or be subject to criminal prosecution for knowingly providing false information.

You and the responsible individuals must repay any benefits you misused or received in error.

If a FoodShare claim is filed against your household, the information on your application, including all Social Security numbers, may be referred to federal and state agencies, as well as private claims and collection agencies, for claims collection action.

FoodShare Intentional Program ViolationFraud or intentional program violations by a person in your household may result in his or her disqualification from FoodShare. This means the person will not be able to get FoodShare benefits: For one year after the first violation. For two years after the second violation. Permanently for the third violation.

Any member of the household who intentionally breaks any of the following rules can be barred from the FoodShare program for the time specified above: Trading, selling, buying, or altering FoodShare

benefits, including the attempt to trade, sell, buy, or alter FoodShare benefits online and/or in person.

Allowing another person to use your FoodShare benefits to purchase food that is not for your household.

Returning items purchased with FoodShare benefits for cash or gift cards.

Using FoodShare benefits to buy or trade for ineligible FoodShare items, like alcohol, tobacco, or rent.

Using another person’s FoodShare benefits, identification card, or other documentation.

Some examples of fraud or an intentional program violation are below:1. Mark is the only person in his family getting

FoodShare benefits. Mark finds out he is going to jail for the month, so he gives his QUEST card to his friend, Sally, to do her grocery shopping while he is in jail.

2. John goes to the store and buys a turkey with his FoodShare benefits. The next day he returns the turkey and says he does not have a receipt and does not tell the store he purchased it with his QUEST card. The store issues him a gift card, and John buys alcohol with it.

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3. Shelly is low on money; she is currently getting FoodShare benefits but has already spent her benefits for the month. To save money on groceries, Shelly offers her sister, Judy, $50 for $100 of Judy’s FoodShare benefits. Judy agrees and takes Shelly grocery shopping with her QUEST card.

Depending upon the value of misused benefits, the person who committed the fraud or program violation can also be fined up to $250,000 and/or imprisoned up to 20 years.

Sometimes there are bigger penalties, even if this is your first intentional program violation. For example: If charged criminally, a court can also bar a person

from the FoodShare program for an additional 18 months.

If convicted of trafficking benefits of $500 or more, a person will never be allowed to get FoodShare again.

If you trade FoodShare for a controlled substance like drugs or alcohol, you will not be allowed to get FoodShare for 24 months or will never be allowed to get FoodShare again if it is your second violation.

If you trade FoodShare for guns, ammunition, or explosives, you will never be allowed to get FoodShare again.

You will not be able to get benefits for 10 years if you are found to have made a false statement about your identity or where you live in order to receive multiple benefits at the same time.

Fleeing felons and probation or parole violators cannot get FoodShare benefits. These individuals may also be subject to further prosecution under other applicable federal laws.

Health Care OverpaymentsIf you get health care benefits that you are not eligible for, you may have to pay them back. For example, you may have to pay back benefits if you fail to report a change in your household’s circumstances and, as a result, get more benefits than you should. You will not have to pay back benefits if your agency makes an error and, as a result, you get more benefits than you should.

Health Care FraudYou may be fined up to $25,000 and have to pay back triple the amount of benefits received and be imprisoned for up to six years for committing fraud if you:

Intentionally give false or incomplete information on your application for health care.

Intentionally give false or incomplete information while you are a recipient of health care.

Use another person’s ForwardHealth card to get health care services or prescription drugs for yourself.

Let someone else use your ForwardHealth card to get health care services or prescription drugs.

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General Program Information

Do You Have Questions?If you have a question, please read this handbook to see if your question is answered. If you cannot find the answer, contact your agency or call Member Services at 800-362-3002.

You should keep this handbook for one year or until you get a new one. You will get a new handbook once a year. If you are enrolled in more than one program (for example, BadgerCare Plus and FoodShare), you may get a copy of this handbook for each program in which you are enrolled.

Program Income and Asset LimitsSome income and asset limits are based on federal poverty level guidelines and/or federal program rules.

The limits in this booklet are based on the October 1, 2018 (FoodShare), and February 1, 2019 (health care), federal guidelines, which may change each year. For income limits, see Appendix A: Program Income Limits on page 55. For asset limits, see each individual program section. You can also get the income limits online at www.dhs.wisconsin.gov/forwardhealth/ resources.htm or by calling Member Services at 800-362-3002.

ForwardHealthForwardHealth is the umbrella term used for all of the health care and nutrition assistance benefit programs offered through the Wisconsin Department of Health Services. The following ForwardHealth programs are available for those who meet the program rules.

Nutrition AssistanceFoodShare Wisconsin(Also known as the Supplemental Nutrition Assistance Program, or SNAP. Formerly food stamps)

Assistance buying the food you need for good health.

Health CareBadgerCare PlusHealth care for children, pregnant women, and adults (with or without dependent children).

BadgerCare Plus Prenatal PlanHealth care for pregnant women who cannot get BadgerCare Plus because of immigration status or who are inmates of a public institution.

Plans for People Who Are Elderly, Blind or DisabledHealth care for people who are elderly, blind, or disabled. People qualify for one or more of the following plans depending on their age, income, assets, and the type of care they need: Medicaid for the Elderly, Blind, or Disabled Medicaid Purchase Plan Wisconsin Well Woman Medicaid Katie Beckett Medicaid Long-Term Care

o Home and Community-Based Waivers o Children’s Long-Term Support Waiver Program o Family Careo Family Care Partnershipo PACE (Program of All-Inclusive Care for the

Elderly)o IRIS (Include, Respect, I Self-Direct)o Institutional Medicaid (hospital, nursing home,

institutions for mental disease)

Limited Coverage PlansThe following plans provide limited coverage or financial assistance: Family Planning Only Services Emergency Services SeniorCare Prescription Drug Assistance Tuberculosis-Related Medicaid Medicare Savings Program

Who Can Enroll?FoodShare WisconsinAnyone can apply for FoodShare. You may be able to enroll if all of the following are true: Your family income is at or below the monthly

program limit (see Appendix A: Program Income Limits on page 55).

You are a Wisconsin resident. You are a U.S. citizen or qualifying immigrant.

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BadgerCare PlusYou may be able to enroll if all of the following are true: You are one of the following:

o A child age 18 or younger with income at or below 300% of the federal poverty level.

o An adult with income at or below 100% of the federal poverty level.

o A pregnant woman with income at or below 300% of the federal poverty level.

o A young adult, under age 26, and you were in a foster home, court-ordered Kinship Care, or subsidized guardianship when you turned 18 years of age—regardless of your income.

You are a Wisconsin resident. You are a U.S. citizen or qualifying immigrant (see

“Note” under BadgerCare Plus Prenatal Plan).

BadgerCare Plus Prenatal PlanPregnant women who cannot get BadgerCare Plus because of immigration status (see “Note” following this paragraph) or who are inmates of a public institution can enroll in the BadgerCare Plus Prenatal Plan. Even though enrollment in this plan is based on pregnancy, you are able to get all BadgerCare Plus-covered services while enrolled.

NOTE: If you are not a U.S. citizen or qualifying immigrant, you may be able to get help through the Emergency Services or Prenatal Services plan. Your immigration status will not be shared with the U.S. Citizenship and Immigration Services (USCIS).

Wisconsin Medicaid for the Elderly, Blind or Disabled (EBD)You may be able to enroll if all of the following are true: You are a Wisconsin resident. You are age 65 or older, blind, or disabled. Your family income and assets are at or below the

monthly program limit (see Appendix A: Program Income Limits on page 55).

You are a U.S. citizen or qualifying immigrant.

Wisconsin Well Woman MedicaidWell Woman Medicaid is a full-benefit health care plan. Women enrolled in this plan will not be enrolled in an HMO.

Enrollment is limited to women who have been diagnosed with and are in need of treatment for breast or cervical cancer or certain precancerous conditions of the cervix.

Women must be enrolled in one of the following programs before they can initially enroll in Well Woman Medicaid: Wisconsin Well Woman Program through Well

Woman Program local coordinating agencies Family Planning Only Services BadgerCare Plus

You may be able to enroll in Well Woman Medicaid if all of the following apply: You are under age 65. You are a U.S. citizen or qualifying immigrant. You are a Wisconsin resident. You have a diagnosis of breast or cervical cancer or

a precancerous condition of the cervix. You need treatment for breast or cervical cancer or a

precancerous condition of the cervix, as identified by the diagnosing provider for the Wisconsin Well Woman Program, Family Planning Only Services, or BadgerCare Plus.

You are not covered by private or other public health insurance for treatment of your breast or cervical cancer.

NOTE: Refer to the Limited Coverage Health Care Plans section for information on who can enroll in limited benefit plans.

Help From OthersCertain people and organizations can help you with your eligibility and/or benefits for programs you are applying for or are enrolled in. This includes legal guardians, powers of attorney, conservators, and authorized representatives.

Legal Guardian, Power of Attorney, and ConservatorA legal guardian of the estate, legal guardian of the person and the estate, legal guardian in general, power of attorney, or conservator is a person who has been appointed to act on behalf of another person who is unable to care for himself or herself.

A legal guardian of the estate, legal guardian of the person and the estate, legal guardian in general, power

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of attorney, and conservator can act on your behalf in all matters related to your eligibility and benefits.

Your legal guardian, conservator, or power of attorney must send copies of the documents about his or her appointment to your agency. Your legal guardian, conservator, or power of attorney cannot act on your behalf until your agency has those documents.

Authorized RepresentativeAn authorized representative is a person or an organization that is familiar with your household’s circumstances and that you trust to act on your behalf.

An authorized representative may do any or all of the following on your behalf: Apply for or renew benefits Report changes to your information Work with your agency on any matters related to

your benefits File grievances and appeals about your eligibility for

programs you are applying for or are enrolled in

If you are applying for or are enrolled in a health care program (for example, Wisconsin Medicaid, BadgerCare Plus, or Family Planning Only Services), you can also choose to have your authorized representative do all of the following: Get your ForwardHealth card instead of you Enroll you in an HMO (health maintenance

organization) Talk to Member Services or your HMO about a bill,

service, or other medical information, including protected health information (PHI)

File grievances and appeals about your health care services (for example, treatment and bills)

This is only an option if your authorized representative is a person and not an organization.

You can appoint an authorized representative for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, and Caretaker Supplement through:

ACCESS when you first apply. One of the paper forms:

o Appoint, Change, or Remove an Authorized Representative: Person form, F-10126A, if your authorized representative is a person.

o Appoint, Change, or Remove an Authorized Representative: Organization form, F-10126B, if

your authorized representative is an organization.

The Health Insurance Marketplace.

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Nutrition Assistance

FoodShare WisconsinHow to ApplyYou can apply online at access.wisconsin.gov, by phone, by mail, by fax, or in person. If you choose to apply by mail or by fax, complete the FoodShare Application (F-16019B). You can get the application online at www.dhs.wisconsin.gov/forwardhealth/ resources.htm or from your agency.

Send the signed and completed application, along with any required proof (see Appendix D: Examples of Proof on page 63), to:

If you live in Milwaukee County, use the following address:

MDPUPO Box 05676Milwaukee, WI 53205

Or fax: 888-409-1979

If you do not live in Milwaukee County, use the following address:

CDPUPO Box 5234Janesville, WI 53547-5234

Or fax: 855-293-1822

Everyone who applies for FoodShare must have an interview. The interview will be done by phone unless you want your interview in person at your local agency.

You will be notified of the status of your application in writing within 30 days from the day your agency gets your application unless you qualify for Priority FoodShare Services.

Priority FoodShare ServicesYou may be able to get FoodShare within seven days of completing and submitting your application and/or registration form if any of the following are true: Your household has $100 or less available in cash or

in the bank and expects to receive less than $150 of income this month.

Your household has rent/mortgage or utility costs that are more than your total gross monthly income (available in cash or in bank accounts for this month).

Your household includes a migrant or seasonal farm worker whose income has stopped.

Work Requirement for Able-Bodied Adults Ages 18 Through 49Certain adults ages 18 through 49 with no minor children living in the home may only get three months of time-limited FoodShare benefits in a 36-month (three-year) period unless they meet the FoodShare work requirement or are considered exempt. This work requirement is different from the work registration requirement.

There are three ways to meet the work requirement:1. Work at least 80 hours each month.2. Take part in an allowable work program at least 80

hours each month, such as: FoodShare Employment and Training (FSET). Wisconsin Works (W-2). Certain programs under the Workforce

Innovation and Opportunity Act (WIOA).3. Both work and take part in an allowable work

program for a combined total of at least 80 hours each month.

You will get information about the FSET program if you are enrolled in FoodShare.

You may be considered exempt and may not need to meet the work requirement if any of the following are true: You are living with a child under age 18 who is part

of the same FoodShare household. You are the primary caretaker for a dependent child

under age 6 (whether the child lives in the home or out of the home).

You are the primary caretaker for a person who cannot care for himself or herself (whether the person lives in the home or out of the home).

You are physically or mentally unable to work. This includes if you are experiencing chronic homelessness.

You are pregnant.

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You are receiving or have applied for unemployment insurance.

You are taking part in an alcohol or other drug abuse treatment or rehabilitation program.

You are enrolled in an institution of higher learning at least half-time.

You are age 18 or older attending high school at least half-time.

You are enrolled in W-2 and complying with W-2 requirements.

You are working 30 or more hours per week or are earning wages equal to 30 or more hours per week at the federal minimum wage.

Work Registration Requirement for Applicants and Members Ages 16 Through 59All FoodShare applicants and members ages 16 through 59 must be registered for work unless they are considered exempt. You will be registered for work at the time you are determined eligible for FoodShare unless you meet an exemption.

You meet an exemption from the work registration requirements if any of the following are true: You are 16 or 17 years old and are not the primary

person in the FoodShare group. You are 16 or 17 years old and are the primary

person in the FoodShare group but are enrolled in school or in an employment and training program at least half-time.

You are found to be unfit for work. This applies if:o You get temporary or permanent disability

benefits from the government or a private source.o You are found to be mentally or physically

unable to work by your agency.o You are verified as unable to work by a

statement from a health care professional or social worker.

You are enrolled in W-2 and complying with the W-2 work requirements.

You are the primary caretaker for a dependent child younger than age 6 (whether the child lives in your home or out of your home). However, if you and another person both have parental control of the child, only one of you can be exempt from the work registration requirements as the primary caregiver of that child.

You are the primary caretaker for another person who cannot care for himself or herself (whether the person lives in your home or out of your home).

You have applied for or are receiving unemployment compensation.

You are regularly taking part in an alcohol or other drug abuse treatment or rehabilitation program.

You are working 30 or more hours per week or earning wages equal to 30 or more hours per week at the federal minimum wage.

You are enrolled at least half-time in a recognized school, training program, or institution of higher education.

You may need to provide proof to your agency if you meet one of these exemptions.

NOTE: Although registration for work is required, taking part in a work program is voluntary.

Work Registration Requirement SanctionIf you do not comply with the work registration requirements and you do not meet an exemption, you will not be able to get FoodShare benefits for a specified sanction period. This includes if you voluntarily and without good cause do any of the following: Turn down a suitable job offer. Quit a job of 30 or more hours per week (or a job

with earnings equal to 30 or more hours per week at the federal minimum wage).

Reduce your work hours to less than 30 hours per week (or your earnings to less than 30 times the federal minimum wage).

Take part in W-2 but do not meet the W-2 program work requirements.

Apply for or get unemployment benefits but do not meet the unemployment compensation program work requirements.

If, during the sanction period, you move to another FoodShare household, the remainder of your sanction period will transfer with you to that household. The length of a sanction period is: First sanction: one month Second sanction: three months Third or subsequent sanction: six months

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You can end a sanction period early if you become exempt from the work registration requirements.

You will need to reapply for FoodShare if you want to get benefits after the sanction period ends. If you are part of a FoodShare group, you will need to let your worker know to update your case instead of having to reapply.

FoodShare Employment and Training (FSET) Program FSET offers FoodShare members free services to build job skills and find jobs. If you need help finding a job, need to meet the work requirement, or want to increase your skills, FSET may be able to help you.

FSET can help with: Job searches and job referrals. Job skills assessment. Career planning. Job training and education. Work experience. Transportation, child care, and other work-related

costs. Referrals to other community services. Meeting the work requirement.

Ask your agency about the FSET services available in your area. Certain adults may choose to participate in the FSET program as a way to meet the work requirement.

How Your FoodShare Benefits Are CalculatedFoodShare benefits are based on a sliding scale. To calculate your benefit amount, your agency will look at the number of people in your home, as well as your household income minus any income credits and other credits you are eligible for.

Household IncomeMost types of income are counted. After all your household’s countable income is added together to get your gross income, you will be given credit for some of the bills you pay.

Income CreditsCertain credits for shelter, dependent care, and child support are subtracted from your gross monthly income to find your net monthly income. The FoodShare benefit amount is based on the number of people in your

household and your net monthly income (see Appendix A: Program Income Limits on page 55).

Other CreditsFor FoodShare, if you report and verify certain costs with your agency, you may be able to get up to six credits. Your agency will subtract these credits from your gross monthly income to get your net income. Some households may not get a credit for certain expenses, and not all credits will be the actual amount reported and verified.

Your household may get the following credits: Standard Credit: All households will get this

credit, which is based on family size:

Family Size Credit1-3 $1644 $1745 $204

6 or more $240

The Standard Credit may change by a small amount each year.

Employment Credit: If you are employed, 20% of your job income or wages will be subtracted. For example, if your total gross job income each month was $1,000, your Employment Credit would be $200 ($1,000 x 20% = $200).

Medical Expense Credit: If you are age 60 or older, blind, or disabled, you will get credit for any medical costs over $35. For example, if you reported and verified $100 each month in medical costs, you would get credit for $65 ($100 - $35 = $65).

Dependent Care Credit: If you attend training, school, or work and pay for dependent care, you will get a credit for the amount you pay for dependent care.

Child Support Credit: You will get a credit for any child support you are required to pay.

Shelter Credit/Standard Utility Credit: o Shelter Credit: The Shelter Credit is based on

your costs for your mortgage, property taxes and property insurance, condo fees, rent, lot rent, and certain utilities.

o Standard Utility Credit If you pay for heat, you will get a Heating

Utility Credit of $456.

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If you pay for two or more of the following utilities, you will get a Limited Utility Credit of $318: Electricity Phone Water Sewer Trash Cooking fuel Air conditioning surcharge

If you only pay for one utility, you will get the utility credit listed below:

Type of Credit AmountElectricity and/orair conditioning surcharge

$130

Phone $33Water or Sewer $86Trash $23Cooking Fuel $36

o Maximum Shelter/Standard Utility Credit:Group 1: Households that have a member who is age 60 or older, blind, or disabled do not have a maximum Shelter Credit limit.

Group 2: Households that do not have a member who is age 60 or older, blind, or disabled can only get the maximum allowed Shelter Credit of $569.

If your household falls into either group, you will get the Shelter Credit if the shelter amount you are obligated to pay and your Standard Utility Credit are more than 50% of your net income (after other credits have been subtracted).

Example of Group 2 Households: If your (adjusted) net income was $1,000, 50% would be $500 ($1,000 x 50% = $500). If your reported shelter cost was $700 and you added the Heating Utility Credit ($456), the total would be $1,156. Your Standard Shelter Credit would be $569, the maximum Shelter Credit allowed ($1,156 - $500 = $656).

Examples of How Income and Credits are CalculatedThe following are examples of how income and credits are calculated for FoodShare.

For the income limits and maximum allotments, see Appendix A: Program Income Limits on page 55.

Example 1: A two-person household with a person who is elderly, blind, or disabled applied for FoodShare with reported and verified gross monthly income of $828, monthly medical costs of $41.91, monthly shelter costs of $343.78, and monthly utility costs of $293 for non-heat electric and phone.

The household’s gross income is less than the gross income limit for two people ($2,820), so this household would pass the gross income test.

The next step would be to figure the household’s credits and subtract them from the gross income ($828) to get the household’s adjusted income:

$828.00 Gross income- $167.00 Standard Credit- $6.91 Medical costs over $35= $654.09 Adjusted income

To calculate the Shelter/Standard Utility Credit, the total shelter costs and the $318 Standard Utility Credit would first be added together. Then, one-half of the adjusted income would be subtracted ($654.09 ÷ 2 = $327.45). The amount left would be the Maximum Shelter/Standard Utility Credit.

$343.78 Actual shelter cost+ $318 Utility Credit= $661.78 Total shelter/utility cost- $327.45 50% of adjusted income= $334.33 Shelter/Utility Credit

$657.09 Adjusted income- $334.33 Excess Shelter/Utility Credit= $322.76 Net adjusted income

To calculate the amount of monthly benefits, the maximum monthly benefit amount for two people ($355) would be compared to 30% of the net adjusted income ($322.76 x 30% = $96.82).

$355.00 Maximum benefits amount- $96.82 30% of net adjusted income= $258.18 Household’s monthly benefitThe monthly benefit for this household would be $258. The amount of benefits will always be rounded down to the nearest dollar.

Example 2: A household of one person applied for FoodShare and reported and verified monthly income of $1,600, monthly shelter expenses of $199, and utility expenses of $300 for heating.

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This person’s gross income is less than the gross income limit for one person ($2,024), so he or she would pass the gross income test.

The next step would be to figure the household’s credits and subtract those credits from the gross income ($1,600) to get the household’s net adjusted income.

$1,600 Gross income- $167 Standard Credit= $1,433 Adjusted income

To calculate the Shelter/Standard Utility Credit, the total shelter costs would first be added to the $452 Heating Standard Utility Credit. Then, one-half of the adjusted income would be subtracted ($1,436 ÷ 2 = $718). The amount left would be the Maximum Shelter/Standard Utility Credit.

$199 Shelter costs+ $452 Utility costs= $651 Total shelter/utility costs

Because 50% of the adjusted net income ($716.5) is more than the actual shelter and utility costs ($651), the person would not get a shelter credit.

$1,433.00 Adjusted net income- 0 Excess Shelter/Utility Credit= $1,433.00 Net adjusted incomex 30%= $429.90 30% of net adjusted income

To calculate the amount of monthly benefits, the maximum monthly benefit amount for one person ($192) would be compared to 30% of the net adjusted income.

$194.00 Maximum benefits amount$430.80 30% of net adjusted income

$16.00 Household’s monthly benefit

Because 30% of the net adjusted income ($429.90) is more than the maximum benefit amount ($194) and the person passed the gross income test, he or she would get the minimum amount of benefits for a one- or two-person enrolled household, which is $16.

Wisconsin QUEST CardYour FoodShare benefits will be put into your QUEST card account using an electronic benefits transfer (EBT) system. You can spend your benefits by using your QUEST card.

You should keep your QUEST card until you are sent a new card or your agency tells you to throw it away. You will not get a new card each month.

You must have your QUEST card with you every time you go to the store to buy food using your FoodShare benefits.

Your Wisconsin QUEST card is a safe and easy way to use your FoodShare benefits. The following sections will explain how your QUEST card works and when to contact QUEST Card Service.

NOTE: You can also watch an online video that gives you information about your QUEST card and how to use it. To view this video, go to www.dhs.wisconsin.gov/foodshare/ebt.htm.

When You Get Your BenefitsEach month that you are enrolled in FoodShare, your benefits will automatically be added to your QUEST card. The date you get your benefits is based on the eighth digit of your Social Security number (see the table below).

Eighth Digit of Your Social Security

NumberDay of the Month Your FoodShare

Benefits will be Available0 2nd

1 3rd

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Eighth Digit of Your Social Security

NumberDay of the Month Your FoodShare

Benefits will be Available2 5th

3 6th

4 8th

5 9th

6 11th

7 12th

8 14th

9 15th

Each month, as your benefits are added to your QUEST account, your balance will go up. As you use your benefits, your balance will go down. Your benefits will be available on the date indicated in the table even if it falls on a weekend or holiday.

Spending Your BenefitsEach month, you may use your QUEST card as often as you want. When you use your QUEST card, there is: No minimum dollar amount you need to spend. No fee to make a purchase.

You can leave as many benefits in your account as you wish at the end of each month to use in a future month. However, if you do not use your QUEST card for one year, any benefits older than 365 days will be removed from your account.

NOTE: You must have your QUEST card with you at the store to buy food with your FoodShare benefits.

You can use your benefits to buy foods such as: Breads and cereals. Fruits and vegetables. Meats, fish, and poultry. Dairy products. Seeds and plants to grow food for your family to eat.

You cannot use your benefits to buy: Nonfood items (pet foods, paper products, soaps,

household supplies, grooming items, toothpaste, cosmetics, etc.).

Beer, wine, liquor, cigarettes, or tobacco. Food that will be eaten in the store. Hot foods (food cooked and served hot at the store). Vitamins and medicines.

You also cannot use your benefits to pay for deposit fees on containers, such as glass milk bottles and other returnable soft drink cans or bottles.

If you eat at a group meal site for senior citizens or have your meals delivered to your home, you can use FoodShare benefits to pay for those meals if the site or provider is authorized to accept the QUEST card.

You can also use your benefits at any of the following places if the facility is authorized to accept the QUEST card: Drug and alcohol treatment center Domestic violence shelter Homeless shelter Group home for people with disabilities

Food that is bought with FoodShare benefits can be replaced if it is destroyed in a household disaster or misfortune. The amount of benefits your agency can replace is the actual amount of food that was destroyed, but not more than the monthly amount of benefits your household got in that month. You must ask your agency for replacement benefits within 10 days of the day your food was destroyed.

Authorized Buyers A FoodShare authorized buyer is a person who can use your FoodShare benefits to buy food for your household.

Both you and your authorized buyer will get a QUEST card. Your authorized buyers QUEST card will have his or her name on it. Your QUEST card will have your name on it.

If you choose an authorized buyer, be sure it is someone you can trust. Any account transactions your authorized buyer makes are considered authorized by the head of the household, and benefits will not be replaced. If any FoodShare program rules were broken, you, as the primary cardholder, may be held responsible. You can appoint an authorized buyer by filling out and submitting the Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits form, F-16004.

Account BalanceAlways check your account balance before you shop. If you do not know your balance, you can do any of the following: Call QUEST Card Service at 877-415-5164. Look at your last receipt.

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Go to www.ebtedge.com. Click on Cardholder Login and enter your QUEST card number.

Use the ebtEDGE mobile app.

You should get a printed receipt when you buy food with your QUEST card.

The receipt will show your account balance. If you do not get a printed receipt, ask for one.

The receipt should have the following information. Some receipts may have more information than listed.

1. Terminal Location: This is the store information or where the swipe card machine is located.

2. Terminal Identification Number: This identifies the swipe card machine you used.

3. Merchant Identification Number: This number tells you who the merchant is or at what store you shopped.

4. Transaction Sequence Number: This is the number of sales made on the swipe card machine for that day.

5. Clerk Number: This number identifies the sales clerk who helped you at the checkout line.

6. Transaction Date and Time: This is the date and time of your grocery purchase.

7. Card #: This shows the last four digits of your QUEST card number.

8. Posting Date: This is the date your transaction or purchase is posted.

9. Balance: This is your FoodShare balance. It shows your balance before you shopped, the amount of benefits you are using for this purchase, and the amount of benefits you have left on your QUEST card.

10. Transaction Amount/Results: This shows the amount of your transaction or purchase and if your purchase was approved.

If you buy groceries that are more than the amount in your account, tell the clerk what amount you want to subtract from your QUEST card account. You will have to pay for the rest with your own money.

Keep in mind that you cannot get cash from your QUEST card.

You can find out what your last 10 purchases or deposits were online at www.ebtedge.com, using the ebtEDGE mobile app, or by calling QUEST Card Service at 877-415-5164. You may also ask for a written history of the purchases and deposits to your account for the past three calendar months by calling QUEST Card Service.

If you find a mistake in your account balance, call QUEST Card Service right away. When you speak with someone, make sure to ask for the name of the person you speak to and also ask for a ticket number. The ticket number is a code that will help you prove that you called and reported the mistake.

If a computer problem occurs that takes away or adds benefits to your account in error, a correction may be made to your balance. The correction could affect your current or future month’s balance.

You will get a letter in the mail if it will lower your balance. If you do not agree that the correction is right, you may ask for a fair hearing. See the Fair Hearings section on page 50 for more details.

Selecting a Personal Identification Number (PIN)When you get your QUEST card in the mail, instructions are included that tell you to select a PIN. You will need your PIN to access your benefits when using your QUEST card. The following are step-by-step instructions to select a PIN. If you are deaf or hearing impaired, see the Instructions for People Who Are Hearing Impaired section following this section.

1. Select four numbers that are easy for you to remember but hard for someone else to figure out.

2. Have your QUEST card number, the four digits you have selected for a PIN, your date of birth, and the last four digits of your Social Security number (SSN) ready.

3. Call QUEST Card Service at 877-415-5164.

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4. The system will give you several options: Pick the option to select a PIN.

5. Then say or press the numbers for: Your date of birth. The last four digits of your SSN. The four-digit PIN you have selected. You will

be asked to enter your PIN twice.

Instructions for People Who Are Hearing Impaired1. Select four numbers that are easy for you to

remember but hard for someone else to figure out.2. Have your QUEST card number, the four digits you

have selected for a PIN, your date of birth, and the last four digits of your Social Security number (SSN) ready.

3. Call 711 and have the TTY operator call 877-415-5164.

4. There are a couple of options to choose from. Have the operator choose the option to select a PIN.

5. Instruct the operator to say or press: Your date of birth. The last four digits of your Social Security

number. The four-digit PIN you have selected. The

operator will need to do this step twice.

Keep Your PIN SafeNever give your PIN to anyone, including your agency, family members, the grocery clerk, store manager, or other store personnel. Anyone who knows your PIN will have access to your benefits, and you, as the cardholder, will be responsible for any transaction made on the card.

Benefits will not be replaced if your card is used by an authorized buyer, authorized representative, or any other person you give your QUEST card and PIN to.

If You Forget Your PINIf you do not remember your PIN, call QUEST Card Service and choose a new PIN. If you are in the grocery store and enter the wrong PIN, you have two more chances that day to enter the right PIN. If you do not enter the right PIN by the third try, a lock will be put on your card, and you will not be able to use your card until the next day.

NOTE: Do not write your PIN on your card or on anything you keep in your wallet or purse. You should call QUEST Card Service at 877-415-5164 and select a new PIN if you think someone else knows your PIN.

Problems With Your QUEST CardIf your QUEST card does not work, call QUEST Card Service at 877-415-5164. If you still need help, contact your agency.

If you notice an error on your account, call QUEST Card Service at 800-415-5164 to report the error. You will get a letter with a decision about the error. If you disagree with the decision, you may file for a fair hearing. Information about filing for a fair hearing will be in your letter.

Error MessagesCall QUEST Card Service if you get an error message when using your QUEST card. These are some examples of error messages and solutions: Card not on file. Insufficient balance: You have tried to spend more

benefits than you have in your account. Put back some of your groceries or pay the remaining amount due with cash or another form of payment.

Invalid PIN: You have entered the PIN incorrectly. If you enter the wrong PIN three times on the same day, a lock will be put on your card until the next day.

Inactive card: You did not select a PIN.

Taking Care of Your QUEST CardListed below are some helpful tips for using your QUEST card. These tips may help you protect your QUEST card and reduce the need for you to get replacement cards in the future (you may get one free replacement card per calendar year, but additional replacement cards will cost $2.70 each): Keep your QUEST card in a safe place. Take care of your QUEST card like you would a

credit card. Do not use your QUEST card to scrape windshields,

open door locks, etc. Keep the magnetic strip clean and free from

scratches. Store your QUEST card in a wallet or purse. Keep your QUEST card away from magnets, such as

purse or handbag clasps and televisions.

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Never tell anyone your PIN. Do not throw away your QUEST card.

If Your Card Is Lost or StolenAs soon as you know you have lost your QUEST card or it has been stolen, call QUEST Card Service at 877-415-5164. Your card will be canceled when you call. If someone uses it before you call to cancel your card, your benefits will not be replaced. Once your card is reported lost or stolen, no one will be able to use your card. A replacement card will be mailed to you on the next business day.

If any QUEST card on your account is lost or stolen, you may have to pay a $2.70 fee to replace it. The fee will come out of your FoodShare benefits. If your account does not have funds to pay for the fee, it will be paid when benefits are added to your account. A cardholder will get one free replacement QUEST card each calendar year (January 1 to December 31).

If Your Card Is DamagedIf your card is damaged or the store must manually key your card number each time you use your card, call QUEST Card Service and request a replacement card.

Monitoring of Excessive Replacement QUEST CardsWisconsin is required to monitor the number of replacement QUEST cards each FoodShare group is issued. If you get five or more replacement QUEST cards in a rolling 12-month period, the Office of the Inspector General may review your QUEST card account for possible misuse of your FoodShare benefits.

Refer to the tips in the Taking Care of Your QUEST Card section on page 15 to help you protect your QUEST card and reduce the need for you to get replacement cards in the future.

Using Your CardYour FoodShare benefits will be put into your FoodShare account using an electronic benefits transfer (EBT) system. Once your benefits are in your account, you can use your QUEST card to buy food at stores and at some farmers markets that accept EBT payments. To pay for your food, swipe your QUEST card at the swipe card terminal in the checkout line, and enter your personal identification number (PIN).

If the swipe card terminal is not working, the store may choose to handle the purchase by using a paper form and calling QUEST Card Service.

If your store chooses to complete a paper form, the following steps are required:1. The clerk must fill out the paper form with the

following information: QUEST card number Your name (or FoodShare member’s name) Merchant identification number Type of transaction (purchase or refund) Amount of purchase or refund Store name and address

2. The clerk must call the QUEST merchant number for an authorization. If the authorization is for a purchase, the clerk will be told whether or not you have enough benefits in your FoodShare account to purchase your groceries.

Once the clerk receives authorization, the clerk will write in the date and time of the call, the amount authorized, and an authorization number.

3. You will be required to approve and sign the paper form. You will get a copy of the form for your records.

A hold for the amount of purchase will be placed on your account to make sure the store is able to complete the transaction and receive payment.

Some small stores, farmers markets, or route vendors may also use a paper form that you will need to sign.

Store AdjustmentsA store may need to increase or decrease the amount of your QUEST card purchase to correct an error (for example, a system error). You will get a letter that explains why the adjustment is needed. If you do not agree with the adjustment, you will have 15 calendar days from the date of the letter to file for a fair hearing. The amount of the adjustment may stay in your account until a fair hearing decision is made.

Returning a PurchaseIf you need to return an item to the store, take the item, store receipt, and your QUEST card to the store where you bought the item. The store will put your benefits back into your account. You will be able to use these benefits right away. You will not get cash back.

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If You MoveIf you plan to move, contact your agency to report your new address. If a card is mailed to your old address, it will not be forwarded to your new address.

If you move out of state, report it to your agency. You should still be able to use any benefits you have on your Wisconsin QUEST card in your new state. If you cannot find a store in your new state that accepts the Wisconsin QUEST card, contact the Wisconsin agency that issued the FoodShare benefits. To keep getting benefits in your new state, you must apply there.

NOTE: If you get a new card in the mail, you must call QUEST Card Service at 877-415-5164 within 15 days to activate your new card. Your old card will be deactivated or closed 15 days from when your new card is issued.

Keep Your QUEST CardEven if you stop getting FoodShare benefits, do not throw away your QUEST card. If you get FoodShare benefits again, they will be put on your last active QUEST card. Only throw away your QUEST card if you are told to do so or you are sent a new card.

FoodShare Rules and ResponsibilitiesIf you are getting FoodShare benefits, you must comply with FoodShare program rules to keep getting benefits.

OverpaymentsOverpayments are benefits you received but should not have. You must repay benefits you received in error, even if it is the agency’s fault and not your own. If federal and state law requires you to repay benefits and you do not do so, it could result in collection actions, such as: Federal or state tax refund interceptions: Tax refund

interceptions mean that the State of Wisconsin can take any FoodShare overpayment from any tax refunds you are owed.

Credit or lien and levy against any real property: If a lien is placed on your home, you cannot sell or trade your home until the overpayment is paid. A levy gives the State of Wisconsin the legal right to keep or sell your property as security for a debt.

Wage assignment: Wage assignment takes any FoodShare overpayment from your job income or wages before you are paid.

Quality Control ReviewYour FoodShare case may be randomly selected by the Wisconsin Department of Health Services for a quality control review. These reviews are to make sure that members are getting the right benefits. As a condition of ongoing FoodShare eligibility, members are required to cooperate with state and federal quality control reviews.

You will need to complete the quality control review to continue to get benefits.

Reporting ChangesIf your household income goes over the 130% income limit for the reported household size, you must report it to your agency by the 10th of the following month.

Household Size Income Limit1 $1,3542 $1,8323 $2,3114 $2,7202,7905 $3,1883,2696 $3,6563,7487 $4,1244,2278 $4,5924,705

For households with more than eight members, add $479 for each additional member.

The income limits listed are based on the October 1, 2019, federal guidelines, which may change each year.

The income limits by household size will also be listed on your latest enrollment letter.

If the work hours of a household member with time-limited FoodShare benefits drop below 80 hours per month, you must report this change to your agency by the 10th of the month following a month in which his or her work hours fall below 80 hours per month (see the Work Requirement for Able-Bodied Adults Ages 18 through 49 section on page 8).

Changes can be reported in the following ways: Online at access.wisconsin.gov. On paper using the FoodShare Income Change

Report (F-16066). You can get this form online at www.dhs.wisconsin.gov/forwardhealth/ resources.htm or by calling your agency.

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By contacting your agency by phone, in writing, or in person.

FoodShare Six-Month ReportingYou may be required to complete a FoodShare Six-Month Report form to verify information on file for your household.

There are different ways to submit your FoodShare Six-Month Report form. Your letter will tell you how.

You will need to send proof of the information you report on the form. Your agency will use the information on your completed form and the proof you provide to update your information. See Appendix D: Examples of Proof on page 63 to learn more.

NOTE: If you do not complete the FoodShare Six-Month Report form and provide proof of your answers by the due date, you may lose your FoodShare benefits.

Elderly, blind, and disabled households do not need to complete a Six-Month Report form.

Homeless and migrant households will not need to complete a Six-Month Report form but will need to complete a renewal.

RenewalsOnce enrolled in FoodShare, you must complete a renewal at least once per year. The renewal is to make sure you still meet all program rules and the amount of benefits you get is correct. If you do not complete your renewal, your benefits will end.

You will receive a letter in the mail the month before your renewal is due. This letter will also tell you how you can do your renewal.

Example: If your renewal is due in April, your letter would be sent in March. This letter would also give you options on how you can do your renewal: online at access.wisconsin.gov, by phone, by mail, by fax, or in person.

An interview is also required. The interview will be done by phone unless you prefer to have your interview at your agency.

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Full Coverage Health Care Plans

BadgerCare PlusHow to ApplyYou can apply online at access.wisconsin.gov, by phone, by mail, by fax, or in person with your agency.

If you choose to apply by mail or fax, complete the BadgerCare Plus Application Packet (F-10182). You can get the application in the following ways: At www.dhs.wisconsin.gov/forwardhealth/

resources.htm By calling 800-362-3002 From your agency

To get the address and phone number of your agency, go to www.dhs.wisconsin.gov/forwardhealth/imagency/index.htm or call 800-362-3002.

Your completed and signed application, along with any required proof (see Appendix D: Examples of Proof on page 63), should be sent to:

If you live in Milwaukee County, use the following address:

MDPUPO Box 05676Milwaukee, WI 53205

Or fax: 888-409-1979

If you do not live in Milwaukee County, use the following address:

CDPUPO Box 5234Janesville, WI 53547-5234

Or fax: 855-293-1822

You will be notified in writing about your enrollment within 30 days from the day the agency gets your application.

Enrollment DateYou cannot get benefits until your agency gets your application and you have met all program rules. Usually, the earliest enrollment start date will be the first day of

the month that the application is received by your agency. In most cases, you may request backdated coverage for up to three months before the month you submitted your application.

Income Rules and Limits

NOTE: If your application for BadgerCare Plus is denied, your application may be sent to the federal Health Insurance Marketplace (also called the Exchange). For more information about the Marketplace, go to healthcare.gov or call 800-318-2596.

How Income Is CountedThe income of each person in your group will be reviewed. The size of your group (in other words, who is included in your group) depends on your tax filing status, tax relationships, and family relationships. Each person applying for benefits will have his or her own group. This means each person in your home may have a different group size, and income may be counted differently for each person in your home. Your family can still apply on the same application.

NOTE: Income and asset amounts may change each year. You can get current amounts by contacting your agency or by calling Member Services at 800-362-3002.

Who Is Included in Your GroupFor BadgerCare Plus, the following rules will be used to determine who is included in your group:

Relationship Rules: If you are not planning to file taxes and you are not going to be claimed as a tax dependent of someone else this tax year, “relationship rules” will be used to determine who is included in your group. This will include the following people if they live with you: You Your spouse Your children and stepchildren under age 19

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Full Coverage Health Care Plans

If you are under age 19, your group will also include the following people if they live with you: Your parents Your brothers and sisters, including half brothers

and half sisters and stepbrothers and stepsisters, under age 19

Whenever a pregnant woman is included in a group, the group size is increased by the number of babies she is expecting.

Example 1: Billy, age 40, and Sadie, age 39, live together but are not married. They have one daughter together, Courtney, age 16. They are not planning to file taxes.

Billy is not married, so his group includes himself and his daughter, for a group size of two. Sadie’s group includes herself and her daughter, for a group size of two. Courtney is under age 19, so her group includes herself and her parents, for a group size of three.

Tax Rules: If you are planning to file taxes and you are not going to be claimed as a tax dependent of someone else, “tax rules” will be used to determine who is included in your group.

Under tax rules, your group includes you, your spouse, and any tax dependents you are planning to claim, even if they are not living with you. If you have children but you are not claiming them as tax dependents, they will not be included in your group.

Whenever a pregnant woman is included in a group, the group size is increased by the number of babies she is expecting.

Example 2: George, age 42, and Lucy, age 43, are married and planning to file taxes jointly. They live with three children: Toby, age 10; Lindsay, age 8; and Sally, age 16. They plan to claim the two children they have together, Toby and Lindsay, as tax dependents. They will not claim Sally as she is claimed as a tax dependent by her mother, Ellen, who is George’s ex-wife. Even though there are five people in the home, George and Lucy’s group size is four: George and Lucy plus their two tax dependents, Toby and Lindsay.

Example 3: Miles, age 54, and Shauna, age 50, are married and plan to file taxes separately. Miles plans to claim their adult son, Dennis, who is 24 years old, living

out of state, and attending college, as a tax dependent. Miles’ group includes himself; his wife, Shauna; and his tax dependent, Dennis; for a group size of three. Shauna’s group will include herself and her husband, Miles, for a group size of two. Because Shauna is filing taxes but not claiming Dennis, she cannot include him in her group.

If you are planning to be claimed as a tax dependent of someone else, tax rules will be used to determine who is included in your group. Your group will be exactly the same as your tax filer’s group unless one of the following exceptions applies: You are being claimed as a tax dependent by

someone other than your parent. You live with both of your parents, but they are not

filing taxes together (for example, unmarried parents or married parents who are filing separately).

You are being claimed as a tax dependent by a parent who lives outside of your home.

If any of these exceptions apply to you, relationship rules will be used to determine who is included in your group.

Example 4: As described in example 2, George and Lucy are married and planning to file taxes jointly. They live with three children: Toby, Lindsay, and Sally. They plan to claim the two children they have together, Toby and Lindsay, as tax dependents. They will not claim George’s 16-year-old daughter, Sally, because she is claimed as a tax dependent by her mother, Ellen, George’s ex-wife.

Toby and Lindsay do not meet any of the three exceptions listed. They are being claimed by their parents who are both living in the home and filing taxes together, and they are not being claimed by a parent outside of the home. Their group is the same as their tax filer’s group. George and Lucy’s groups have four people (George, Lucy, Toby, and Lindsay), so Toby and Lindsay’s groups also have four people.

Sally does meet one of the three exceptions listed; she is being claimed by a parent (her mother, Ellen, George’s ex-wife) who lives outside of the home. Relationship rules will be used for Sally. Her group will include herself, her parents (George, her father, and Lucy, her stepmother), and her half brother and half sister (Toby and Lindsay), for a group size of five.

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NOTE: For Family Planning Only Services, you are considered a group size of one, and only your own income is counted.

How Income Is CountedOnce the size of your group is determined, your income is reviewed to see if you meet the rules for BadgerCare Plus and to see whose income is counted in your group.

Exceptions: IncomeIn most cases, all of the members in your group will have their income counted unless the member is a child or tax dependent of someone else in your group. A child’s or tax dependent’s income will not be counted if he or she expects to have: Less than $12,200* in taxable income from a job in

the current tax year or Less than $1,100* in taxable income from a source

other than a job or self-employment in the current tax year.

*This amount may change each year.

Child support, SSI (Supplemental Security Income), Social Security, workers compensation, and veterans benefits are not counted in the $1,100 amount.

If the child or tax dependent expects to get more than the amounts listed in the current tax year, the child or tax dependent is required to file taxes, and his or her income will be counted in the group.

Example 5: As described in example 1, Billy and Sadie live together but are not married. They have one daughter together, Courtney, age 16. They are not planning to file taxes. Billy’s group includes himself and his daughter, for a group size of two. Billy has $1,500 each month from a job, and Sadie has $600 each month in self-employment. In the month they apply for BadgerCare Plus, Courtney has a summer job that pays $800 each month. Courtney knows she will only be working for three months, so she does not expect to earn more than $12,200 in the current tax year and will not be required to file taxes.

Courtney is the child or tax dependent of Billy and is in his group, but she does not meet the IRS requirements for being required to file a tax return. Her income will not be counted in Billy’s group. Because Sadie and Billy

are not married, Sadie is not included in Billy’s group, so her income will not be counted in his group. Billy’s income will be the $1,500 each month he has from his job, and his group size is two.

NOTE: If someone is a child or tax dependent but is not the child or tax dependent of a person in the same group, the income exception does not apply.

Example 6: Joanie, age 35, lives with and cares for her niece, Gillian, age 12. Joanie also claims Gillian as a tax dependent. Joanie’s group is made up of herself and her tax dependent, Gillian, for a group size of two. Because Gillian meets one of the three tax rule exceptions (her tax filer is not her parent), relationship rules will be used. Gillian does not live with her parents, brothers, or sisters, so Gillian will be a group size of one. Joanie earns $2,000 each month at her job. Gillian receives a Social Security payment of $600 each month.

In Joanie’s group, her income of $2,000 each month is counted but not Gillian’s Social Security income. This is because Gillian is in Joanie’s group and is the child or tax dependent of Joanie. Because Social Security income does not count toward the $1,100 of income from a source other than a job, Gillian is not expected to be required to file taxes. Joanie’s income is $2,000 each month, for a group size of two.

For Gillian’s group, her Social Security income of $600 each month is counted. This is because she is the only person in her group. Even though she is both a child and a tax dependent, she is not the child or tax dependent of someone else in her group. Joanie’s income will not be counted for Gillian because Joanie is not in Gillian’s group. Gillian’s income is $600 each month, for a group size of one.

Types of Income That Are CountedMost taxable income will be counted for BadgerCare Plus. This is true for people who are, and who are not, filing taxes.

Even though Social Security income is not usually taxable, this income type must be counted for BadgerCare Plus.

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Common income types that are counted for BadgerCare Plus include the following: Income from a job Net self-employment income Social Security Unemployment compensation Alimony The taxable amount of pensions, retirement benefits,

and annuities Tribal per-capita payments from gaming revenues

If you have self-employment income, your tax return from last year will be used to get your average monthly net income from your business. If your business has had a change in circumstances, your net monthly average will be what your business has made since the change.

The same business expenses that are allowable deductions by the IRS are allowable deductions for BadgerCare Plus. This includes depreciation and depletion. Any losses you have from self-employment will offset your other income (and that of your spouse if you are filing jointly), such as income from a job.

Example 7: Bob and Barbara are both adults over 19 years of age, married, and filing taxes jointly. Barbara earns $1,200 each month from a job. Bob is self-employed, and this year he has an average monthly loss of $200 from his self-employment. Because Bob and Barbara are filing jointly, the self-employment loss from Bob’s business will offset Barbara’s income. The monthly net income for Bob and Barbara will be $1,000 each month.

$1,200 Barbara’s income- $200 Monthly loss from Bob’s business= $1,000 Net income

Some of the income types that are not counted for BadgerCare Plus include: Child support. Income earned while providing live-in care but only

in certain situations. (Ask your worker for details.) SSI. Workers compensation. Veterans benefits. Gifts from other people. Some payments to Native Americans from sources

other than gaming revenue.

Income Deductions and DisregardsThere are two types of deductions for BadgerCare Plus:1. Pretax Deductions: Payments that are taken out of

your paycheck before taxes are taken out are pretax deductions. These payments will be subtracted from your gross job income and will lower the amount of income counted from your job.

Allowable pretax deductions include the following: Health insurance premiums Health savings accounts (including flexible

spending accounts) Retirement contributions Parking and transit costs Child care savings accounts Group life insurance

2. Other BadgerCare Plus Tax Deductions: Some or all of the following deductible expenses for tax purposes can be deducted from your income for determining your BadgerCare Plus eligibility, even if you are not planning on filing taxes. Allowable tax deductions are listed on page 1 of the IRS Form 1040 or on Form 1040, Schedule 1, for Tax Year 2018.

Most of these deductions are not common, and they do not include itemized tax deductions, such as charitable contributions or mortgage interest. Some deductions have limits. If your expense is more than the limit, the full amount of the expense will not be deducted from your income.

Deductible expenses include:Student Loan Interest: Interest on a loan that you took out to pay for school is tax deductible. This could be a loan to pay for school for a spouse or a tax dependent. If all your loans are interest free, such as federal subsidized loans, you cannot get the deduction.

If the loan was used for anything besides paying for education or a relative or employer gave you the loan, you cannot get the deduction.

Example: If your student loan payment is $200 per month and part of that payment is $50 in interest, that interest is tax deductible.

Higher Education Expenses: Higher education expenses include tuition and school fees but only if

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those expenses were paid with taxable income. Loans, grants, and scholarships are usually not taxable income, so tuition and school fees paid with loans, grants, and scholarships cannot be deducted. Expenses for books and supplies are only deductible if paid for with taxable income and only if the student has to pay the educational institution for the cost.

Self-Employment Tax Deduction: If you are self-employed and pay self-employment tax, you can deduct half of the self-employment tax that you pay.

Alimony: If you pay spousal support, alimony, or maintenance, you can get this deduction.

Teachers’ Tax-Deductible Expenses: If you are a K-12 teacher and have up to $250 in out-of-pocket work expenses (expenses not paid for by your employer), you can get this deduction.

Self-Employed Savings Plans: If you are self-employed and contribute to a retirement or savings plan for self-employed people and/or your employees, you can get this deduction. Examples of these plans include Simplified Employee Pension (SEP) plans, Savings Incentive Match Plan for Employees (SIMPLE), and Qualified Plan Contributions.

Penalties for Early Withdrawal of Funds: If you paid a penalty to a bank or financial institution for withdrawing funds early from a savings account where money must be left in the account for a fixed period of time, you can get this deduction. Examples include a time savings account, certificate of deposit (CD), or annuity.

Performing Artists’ Tax-Deductible Expenses: If you are a performing artist who has out-of-pocket business expenses (expenses not paid by your employer), you can get this deduction.

You can only get this deduction if you worked for at least two employers who each paid at least $200, did not earn more than $16,000 for your work in a year, and out-of-pocket expenses were more than 10% of your earnings.

If you are unsure whether this deduction applies to you, please see IRS Form 2106 and Instructions for more information.

Military Reserve Members’ Tax-Deductible Expenses: If you are a member of the Armed Forces Reserve and travel more than 100 miles away from home to perform work for the Armed Forces Reserve, you can get a deduction for your travel expenses.

If you are unsure whether you qualify, please see IRS Form 2106 and Instructions for more information.

Out-of-Pocket Costs for a Job-Related Move: If you paid out of pocket (expenses not paid for by an employer) for a job-related move, you can get this deduction. The move must be for a job-related reason, such as starting a new job, and the new job must be at least 50 miles farther from your old home than your old home was from your old job. If you did not have a job before and your new job is at least 50 miles from your old home, you can get this deduction.

If your employer paid for your moving expenses, you cannot get this deduction.

Loss from Sale of Business Property: If you are self-employed and had a loss from the sale or exchange of property that you owned for your business, you can get this deduction.

Individual Retirement Account (IRA) Contributions: If you had income from a job and made contributions to an IRA, you can get this deduction. An IRA is a savings plan that pays a fixed, regular amount to you after you retire. You can get this deduction if you are self-employed and contribute to an IRA that you set up yourself.

Fee-Based Official Tax-Deductible Expenses: If you are a fee-based official and have out-of-pocket business expenses (expenses not paid by the employer), you can get a deduction for those expenses.

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Examples of fee-based officials include chaplains, county commissioners, judges, justices of the peace, sheriffs, constables, registers of deeds, and building inspectors.

If you are unsure whether you qualify, please see IRS Form 2106 and Instructions for more information.

Domestic Production Activities Deduction: If you are self-employed and led the production of things like property, electricity, natural gas, or potable water (as long as these were produced in the United States), or if you were the inventor or creator of software, recordings, or films in the United States, you can get this deduction.

Net Operating Loss (NOL)If you have more deductions than income for the year, you may have a net operating loss (NOL). An NOL can be deducted from income from another year or years. If you have an NOL carryover from a previous year, you may be able to get this deduction.

The IRS has a number of rules for having an NOL. Generally, an NOL is caused by a loss from operating a sole proprietorship business or rental property. The IRS also has rules that limit what can be deducted when calculating an NOL. For example, you cannot deduct capital losses in excess of capital gains. In addition, the NOL deduction cannot exceed 80% of taxable income for losses in tax years after 2017.

For more information about NOL, please see the instructions for completing IRS Form 1040 and IRS Publication 536.

Other Allowable Write-In Expenses: On page 1 of IRS Form 1040, or on Form 1040, Schedule 1, for Tax Year 2018, there is a place for write-in tax deductions that are very uncommon. They include the following list: Contributions to Archer Medical Savings

Accounts Deductions attributable to rents and royalties Certain deductions of life tenants and income

beneficiaries of property Jury duty pay given to the employer because the

juror was paid a salary during duty

Reforestation expenses Costs involving discrimination suits Attorney fees relating to awards to

whistleblowers Contributions to section 501(c)(18)(D) pension

plans Contributions by certain chaplains to section

403(b) plans

If any of these apply to you, you can get the deduction. For more information about these, see the instructions for completing IRS Form 1040.

Income DisregardsThe amount of your income equal to 5% of the federal poverty level will be disregarded in counting your income for BadgerCare Plus eligibility. Children, pregnant women, and people enrolled in Family Planning Only Services will receive an additional disregard in the amount of their income equal to 1% of the federal poverty level.

For all adults, the 5% disregard is already included in the program’s income limit of 100% of the federal poverty level.

For children, pregnant women, and people enrolled in Family Planning Only Services, both disregards (5% and 1%) will be applied by comparing their income to 306% of the federal poverty level (instead of 300%).

Example: Marcy is a pregnant woman who is not married and has no children. She is expecting one baby, so her group size is two. Her income is $4,184 each month, which is 305% of the federal poverty level. Although the income limit for pregnant women is 300% of the federal poverty level, or $4,115.01 each month, she will still be able to enroll in BadgerCare Plus because of the income disregards.

Marcy’s boyfriend, Al, has a group size of one and a monthly income of $1,042, or 103% of the federal poverty level. As an adult, his income limit is 100% of the federal poverty level, or $1,011.67, and the 5% disregard is already included in the income limit. As a result, he is over the income limit and will not be able to enroll in BadgerCare Plus.

Most income limits for children will also apply the 6% disregard (for example, the income limit for backdated coverage—see page 61). Children will only get a 1%

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disregard of their income when determining if they owe a premium.

Medicaid for the Elderly, Blind or DisabledMedicaid provides health care coverage to people who are age 65 or older, blind, or disabled. Disability and blindness determinations are made by the Disability Determination Bureau in the Department of Health Services.

How to ApplyYou can apply for all plans listed below online at access.wisconsin.gov, by phone, by mail, by fax, or in person: Institutional Medicaid (hospital, nursing home,

institutions for mental disease) Medicaid Medicaid Purchase Plan Emergency Services Medicare Savings Program

If you choose to apply by mail or fax, fill out the Medicaid for the Elderly, Blind or Disabled Application Packet (F-10101). You can get the application online at www.dhs.wisconsin.gov/forwardhealth/resources.htm, by calling Member Services at 800-362-3002, or from your agency.

Send the signed and completed application, along with any required proof (see Appendix D: Examples of Proof on page 63), to:

If you live in Milwaukee County, use the following address:

MDPUPO Box 05676Milwaukee, WI 53205

Or fax: 888-409-1979

If you do not live in Milwaukee County, use the following address:

CDPUPO Box 5234Janesville, WI 53547-5234

Or fax: 855-293-1822

To apply for long-term care services through Home and Community-Based Waivers, Family Care, Family Care Partnership, IRIS, or PACE, you must contact your local aging and disability resource center (ADRC). To get the address and phone number of your ADRC, go to www.dhs.wisconsin.gov/adrc/index.htm or call 800-362-3002. If your county does not have an ADRC, contact your local social or human services department for information on requesting these services.

You will receive a written notice about your enrollment within 30 days from the day the agency gets your application.

Enrollment DateYou cannot get benefits until the agency gets your application and you have met all program rules.

The earliest enrollment date will usually be the first day of the month that your completed and signed application is received by your agency. Unless you are a qualified Medicare beneficiary (see page 38), you may request backdated coverage for up to three calendar months before the month you submitted your application.

Income CreditsDetermining which Medicaid plan you can be enrolled in will be based in part on your “countable income.” Countable income is your gross income minus allowed credits. The credits subtracted from your income may vary depending on the plan.

The credit needs to meet the rules of the Medicaid plan before it can be subtracted from your income. In most cases, you must provide proof/verification of the expense to get the credit. The credits you receive will determine if you are able to enroll in Medicaid and under what plan. It will also determine if you will have a cost share.

The following are credits you may be able to get and how they are calculated or what they are for.

1. $65 and One-Half Credit for Earned Income: This credit is only available to people with job income or wages. The $65 and One-Half Credit is calculated by (1) subtracting $65 from your monthly gross job income and wages, (2) dividing the remaining amount by two, and (3) adding back the $65.

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For example: If your monthly gross income from employment is $500, your credit would be $282.50.

$500.00 $435.00 $217.50- $65.00 ÷ 2 + $65.00= $435.00 = $217.50 = $282.50

2. Community Waivers (Group B or B Plus) Basic Needs Credit: As of 2019, this allowance is $951.

3. Community Waivers Personal Maintenance Credit: This allowance is for room, board, and personal expenses, and it consists of three components: (1) the Community Waivers Basic Needs Credit, (2) the $65 and One-Half Credit for Earned Income, and (3) the Special Housing Credit.

$951.00 Community Waivers Basic Needs Credit+ $65 and ½ Credit for Earned Income+ Special Housing Credit= Community Waivers Personal

Maintenance Credit

The sum total of these three components cannot exceed $ 2,313.

4. Cost Associated with Real Property Credit: If you are residing in a nursing home and own property that is listed for sale, you can use some of your income to pay for minimal heat and electricity costs to avoid damage to the home while it is listed for sale. You may be able to get a credit for these costs.

5. Depreciation: If self-employed, you may be able to deduct depreciation from your self-employment income. The amount of the depreciation credit you may be able to get is the same as the amount you claim on your tax forms.

6. Excess Self-Employment Expenses Credit: When there is more than one self-employment business, the losses of one can be credited against the profits of another.

7. Fees to Guardians or Attorneys Credit: You may be able to get a credit for court-ordered guardian and/or attorney fees paid directly out of your monthly income. These are costs paid by you for establishing and maintaining a court-ordered guardianship or protective placement for yourself.

8. Health Insurance Premiums Credit: You may be able to get a credit for the cost of health insurance premiums you are obligated to pay for you or your spouse.

If you and your spouse apply but only one pays the premium, divide the premium equally. Prorate premiums over the months the payments cover.

NOTE: For Institutional Medicaid, the member does not get credit for a premium deduction if he or she is not responsible for the premium payment.

9. Impairment-Related Work Expenses (IRWE) Credit: You may be able to get a credit for costs you expect to incur due to a physical or mental impairment and your employment.

The following are examples of impairment-related work expenses: Modified audio/visual equipment Typing aids Specialized keyboards Prostheses Reading aids Vehicle modification (plus installation,

maintenance, and associated repair costs) Wheelchairs

10. Maintaining Home/Apartment Credit: If you are in a medical institution and you have a house or an apartment or you were residing in an assisted living facility prior to being institutionalized, you may be able to get a credit equal to the cost of maintaining the home, apartment, or room at the assisted living facility, up to $929.77, if both of the following apply:

Your doctor certifies (verbally or in writing) that you are likely to return to the home, apartment, or room within six months.

Your spouse is not living in the home, apartment, or room.

11. Medical/Remedial Expenses Credit: Medical/remedial expenses are used in Institutional Medicaid and Home and Community-Based Waivers programs for cost share calculations and in Medicaid Purchase Plan for premium calculations. They are also used to see if you may be able to enroll in a

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Medicaid deductible plan. Your care manager or an agency worker can help you in calculating your medical/remedial expenses.

Medical expenses are services or goods prescribed or provided by a licensed professional medical practitioner. The amount of the credit is the expense for diagnosis, cure, treatment, or prevention of disease or for treatment affecting any part of the body. You will only get a credit for the costs that you are required to pay and that are not paid for by any other source, such as Medicaid, private insurance, or your employer.

Remedial expenses are costs for goods or services that are provided for the purpose of remedying, relieving, or reducing a medical condition. You will only get a credit for the costs that you are required to pay and that are not paid for by any other source, such as Medicaid, private insurance, or your employer.

12. Personal Needs Credit for Institutional Medicaid: This credit is $45.

13. Special Exempt Income Credit: You may be able to get a credit for the following:

Income used for supporting others (see number 15)

Court-ordered attorney fees Court-ordered guardian and guardian ad litem

fees Legal Expenses Credit: The expense for

establishing and maintaining a court-ordered guardianship or protective placement, including court-ordered attorney or guardian fees

Expenses associated with a self-support plan (see number 16)

Impairment-related work expenses (see number 9)

14. Standard Credit: This credit is $20.

15. Support Payments Credit: You may be able to get a credit for support payments. These are payments that a Medicaid for the Elderly, Blind or Disabled member makes to another person outside of the home for the purpose of supporting and maintaining that person. These payments can be either court ordered or non-court ordered.

16. Plan to Achieve Self-Support (PASS) Credit: A member whose enrollment is based on blindness or disability may get a credit for an approved PASS.

To qualify for this credit, the member must perform in accordance with the self-support plan. The plan must: Be specific, current, and in writing. Be approved by the Social Security

Administration as verified by submission of the plan and the Social Security Administration’s approval letter.

Specify the amount to be set aside and the expected cost and time required to accomplish the objective.

Provide for identification and segregation of goods and money accumulated and conserved.

Program Income and Asset LimitsThe following sections explain how income and assets are counted for each Medicaid plan. Below are definitions of some of the terms used.

Job income and wages: Earned income that you get from a job or employment. Usually this is the gross income that you earn in the form of wages or salary. It also includes net earnings from self-employment.

Other income: Income that you get from sources other than active employment. Examples include Social Security income, annuity or trust income, alimony/maintenance payments, pension or retirement benefits, and veterans benefits.

Counted income: Your gross income minus allowed credits. Each Medicaid plan describes what credits are allowed and how each is calculated.

Income not counted: Income sources that may not be considered when comparing your income to the Medicaid income limits.

Examples of income that is not counted include: Veterans Administration allowances

o Aid and attendanceo Unusual medical expenses

Some payments to Native Americans

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AssetsSome Medicaid plans have different asset limits. The asset limits are listed in each individual plan description. You must include assets you own yourself or own jointly with another person. Do not include the value of personal household belongings (for example, televisions, furniture, and appliances).

Assets can be in the form of cash, property, or other holdings that can be converted to cash. The following are some examples of assets: Cash Savings or checking accounts Certificates of deposit Life insurance policies Trust funds Stocks and bonds Retirement accounts Interest in annuities U.S. savings bonds Property agreements, contracts for deeds,

timeshares, rental property, life estates, livestock, tools, and farm machinery

Keogh plans or other tax shelters and personal property being held for investment purposes

For a complete list of counted assets, contact your agency.

Medicaid does not count some assets. Those not counted may include the following: One vehicle Certain burial assets (including insurance, trust

funds, and plots) Tribal property Clothing Other personal items

Medicaid Standard PlanThe Medicaid Standard Plan is a full benefits plan.

Asset LimitThe asset limit for the Medicaid Standard Plan is $2,000 for a single person or $3,000 for a married couple.

Income TestThere are two steps used for calculating your income to determine whether you qualify for the Medicaid Standard Plan:

1. Certain credits are subtracted from your monthly gross income to calculate the “counted income.” The credits included in the following equation are allowed in this income calculation.

$ Gross income- $65 and ½ Credit for Earned Income- Special Exempt Income Credit- $20.00 Standard Medicaid Credit= $ Counted income

2. Your counted income is compared to the Medicaid income limit. The income limit is based on whether you are single or married. The Medicaid Standard Plan income limit has two parts: an income amount plus a shelter cost allowance.

Medicaid Standard Plan Income LimitThe following are the Medicaid Standard Plan income limits for a single person and a married couple.

Group Size 1 Group Size 2$583.78 $882.05 Income amount

+ $257 + $385.67 Actual shelter cost($833.78) ($1,257.05) (up to maximum)

Medicaid DeductibleAn individual or couple with counted income above $591.67 can qualify for the Standard Plan by meeting a Medicaid deductible.

If your counted income is higher than the Medicaid Standard Plan income limit, your Medicaid deductible is calculated for a six-month period based on the difference between your monthly counted income and $591.67.

Your deductible amount will be listed on the enrollment letter you get after your application is processed.

Calculating Your DeductibleThe following equation shows how your deductible is calculated:

$ Counted income- $591.67 Monthly income limit= $ Monthly amount over income limitX 6 Six-month period= $ Deductible amount

You can use the cost of unpaid and recently paid bills for medical or remedial expenses to meet your deductible. You will need to provide proof of the

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expenses to your local agency. Once your deductible has been met, Medicaid will pay for covered services until the end of the six-month period.

Examples of medical costs include: Health insurance premiums. The portion of medical bills you must pay for

yourself, your spouse, and your minor children after Medicare and private insurance have paid.

Once you have met your deductible, you will have a copay for certain Medicaid-covered services. See Appendix B: Covered Services and Copays for BadgerCare Plus and Medicaid Programs (page 56) for more information about covered services.

Medicaid Purchase PlanThe Medicaid Purchase Plan is a full benefits plan that provides health care coverage for people with disabilities who are working or are enrolled in the Health and Employment Counseling (HEC) Program.

AssetsThe total countable assets of a Medicaid Purchase Plan applicant or member (excluding Independence Accounts—see the Independence Accounts section) cannot be more than $15,000.

Assets owned by the applicant’s spouse do not count toward this limit.

IncomeThe income limit is 250% of the federal poverty level (see Appendix A: Program Income Limits on page 55).

Independence AccountsIf you are enrolled in the Medicaid Purchase Plan, you can set up independence accounts. These accounts will not affect your enrollment.

There is no limit to the number of accounts you may set up, and there is no restriction on how you use the money. Income you deposit while you are enrolled in the Medicaid Purchase Plan will not be counted as an asset. Deposits (earned or other income) in your independence account may total up to 50% of gross earnings over a 12-month period without penalty. If the deposits exceed 50% of your actual gross earnings, a penalty may be assessed.

Income TestThe income limit for the Medicaid Purchase Plan is 250% of the federal poverty level (see Appendix A: Program Income Limits on page 55). Your monthly income—and your spouse’s monthly income if you are living together—is counted for the Medicaid Purchase Plan income test.

$ Gross earned income- $65 and ½ Credit for Earned Income- Impairment-Related Work Expenses

Credit+ Gross other income- $20 Standard Medicaid Credit- Special Exempt Income Credit= $ Counted income for Medicaid Purchase

Plan

Your counted income is compared to the federal poverty level (see Appendix A: Program Income Limits on page 55). If your counted income is less than 250% of the federal poverty level for your group size, you may be enrolled in the Medicaid Purchase Plan. In determining your group size, you, your spouse, and your minor dependent children (natural or adopted) living with you are included. Your stepchildren are not included in the group size.

Medicaid Purchase Plan Premiums and CopaysIf your gross income equals or exceeds 150% of the federal poverty level for your group size, you will need to pay a premium to enroll in the Medicaid Purchase Plan (see Appendix A: Program Income Limits on page 55). In addition to a monthly premium, you may also have copays (see Appendix B: Covered Services and Copays for BadgerCare Plus and Medicaid Programs on page 56).

If you do not pay the monthly premium on time, there may be a period of time during which you cannot be enrolled in the Medicaid Purchase Plan unless there is good cause.

The Medicaid Purchase Plan Consumer Guide has more information about premiums. You will get your guide when you enroll in the Medicaid Purchase Plan.

Long-Term Care ServicesMany people who are elderly, blind, or disabled need help accomplishing activities of daily living and caring

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for their health. This help, referred to as long-term care, includes many different services, such as personal care, housekeeping, or nursing.

Long-term care is provided in people’s homes, in residential care facilities or group homes, in nursing facilities, and in the workplace.

Long-term care includes any service or support that a person needs due to age, disability, or chronic illness that limits his or her ability to perform everyday tasks. Long-term care services go beyond the Medicaid Standard Plan-covered services and are designed to meet the special needs of the elderly and/or people with disabilities.

Long-term care services and supports include the following: Nursing facility services Personal care services Home health services Therapies Disposable medical supplies Durable medical equipment

Long-term care settings may include the following: People’s own homes Nursing homes Residential facilities Community settings Hospitals Institutions for mental disease

Long-term care programs include Institutional Medicaid, Home and Community-Based Waivers, Children’s Long-Term Support Services, Family Care, Family Care Partnership, IRIS, and PACE.

Asset LimitThe asset limit for a person applying for a long-term care plan is $2,000. If the person applying for the long-term care plan has a spouse living in the community, the spouse will be able to keep some assets above the $2,000 limit without affecting the long-term care applicant’s enrollment. See the section on Spousal Impoverishment Protections (page 32) for the asset limit when there is a spouse living in the community.

Income TestThe following are the monthly income limits for the specific long-term care plans (these income limits are explained in the sections that follow): Community Waiver/Family Care Medicaid Level 1

—monthly income limit: $ 2,313 Community Waiver/Family Care Medicaid Level 2

—monthly income limit: $591.67 Institutional Medicaid Level 1—monthly income

limit: $ 2,313

Institutional MedicaidInstitutional Medicaid provides coverage of medical services for those who reside in medical care facilities, such as skilled nursing facilities, intermediate care facilities, institutions for mental disease, and hospitals. In order for you to qualify for Institutional Medicaid, your assets must be lower than the asset limit. The asset limit for one person is $2,000. The asset limit for a married couple is described in the Spousal Impoverishment Protections section (page 32). The income limit is $ 2,313.

There are two ways you may qualify for Institutional Medicaid:1. Your monthly gross income (job income and wages

and other income) is first compared with the Level 1 income limit (see Income Test section on page 30). If your monthly gross income is less than the Level 1 income limit, you may be able to enroll in Institutional Medicaid.

2. If your monthly gross income is greater than the Level 1 income limit, your monthly gross income is compared to the cost of your monthly medical needs. If your monthly gross income is less than your monthly medical needs, you may be able to enroll in Institutional Medicaid.

Medical NeedThe following expenses are used when determining your medical needs for Institutional Medicaid.

$45 Personal needs allowance+ Private care rate of institutional care

where you live*+ Cost of health insurance+ Special Exempt Income Credit+ Other medical costs= $ Medical need*This is the actual cost of the institutional care.

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Full Coverage Health Care Plans

Institutional Medicaid Cost Share CalculationThere may be a monthly cost share for someone enrolled in Institutional Medicaid.

Depending on your income and marital status, you may have to pay toward your cost of care. This is called your cost share. Medicaid will pay for the rest of the Medicaid-covered services.

Your cost share calculation will differ depending on your marital status, whether you have dependents living with your spouse, and the long-term care program in which you are enrolled. (See the description and calculations for your specific long-term care program in this handbook.)

The cost share is calculated as follows:

$ Gross income- $65 and ½ Credit for Earned Income- Cost of the institutionalized person’s

health insurance premium- Special Exempt Income Credit- $45 Personal needs allowance- Home maintenance costs for six

months- Income allocation to a community

spouse or dependents- Medical Remedial Expense Credit= $ Cost share

Home and Community-Based WaiversThese plans enable people who are elderly, blind, or disabled to live in community settings rather than in state institutions or nursing homes. They pay for community services that normally are not covered by Medicaid. To receive long-term care services through these programs, you must: Meet level-of-care requirements as determined by

your care manager. Meet all program rules. Reside in a setting allowed by Home and

Community-Based Waivers policies. Have a disability determination if you are under the

age of 65. Contribute toward the cost of your waiver services if

required. Have assets at or below the asset limit. (The asset

limit for one person is $2,000. The asset limit for a married couple is described in the Spousal Impoverishment Protections section on page 32.)

The three different Home and Community-Based Waivers groups are Group A, Group B, and Group B Plus. You cannot be in more than one group at the same time. You may have a cost share that must be paid each month to keep getting Home and Community-Based Waivers benefits. Your decision letter will let you know if you have a cost share and how much it is. In addition to a cost share, certain services you get will require a copay.

Group A WaiversMembers enrolled in Group A must meet all Home and Community-Based Waivers functional eligibility rules, as well as the income/asset and all other rules for BadgerCare Plus, Medicaid, or the Medicaid Purchase Plan. No additional financial test is required.

As a Group A member, you are not required to pay a monthly cost share, but you still must pay any monthly amount associated with the BadgerCare Plus, Medicaid, or Medicaid Purchase Plan.

Group B WaiversMembers enrolled in Group B must meet all Home and Community-Based Waivers functional eligibility rules and have monthly gross income less than the Community Waiver/Family Care Medicaid Level 1 income limit.

If you are a Group B member, you may have to pay a cost share. The Group B cost share is based on your income and allowable credits. The Group B cost share is calculated by subtracting the following credits, if they apply, from your monthly gross income:

$ Monthly gross income- Community Waivers Personal

Maintenance Credit- Family maintenance allowance- Special Exempt Income Credit- Health Insurance Premiums Credit- Medical Remedial Expenses Credit= $ Cost share

Special Housing CreditThis amount is the total of housing costs (listed) minus $350.

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Full Coverage Health Care Plans

$ Rent+ Insurance (renter/homeowner)+ Mortgage+ Property tax+ Utilities (heat, water, sewer, electric)- $350= $ Special Housing Credit

Group B Plus WaiversIf your monthly gross income is greater than the Level 1 income limit, which is $ 2,313, and you meet the program rules, you may be able to be enrolled in Group B Plus Waivers.

To meet the program rules, you must: Meet a nursing home level of care and Have counted income that is less than your medical

needs.

All Group B Plus members will have to pay a cost share. The Group B Plus cost share is based on your income and allowable credits. The Group B Plus cost share is calculated the same as the Group B cost share.

Family CareFamily Care provides long-term care services for people who are elderly, blind, or disabled. The Family Care income rules are the same as the income rules for Home and Community-Based Waivers. Family Care also provides long-term care services for people who do not need nursing home level of care but need help to accomplish activities of daily living and caring for their health if both of the following apply: The member meets the program rules for any non-

Home and Community-Based Waivers plan. Long-term care services are requested.

To enroll in Family Care, you must be able to enroll in one of the BadgerCare Plus or Medicaid plans.

Family Care PartnershipFamily Care Partnership is a full benefits plan that covers health care and long-term support services for people who are elderly or disabled. Services are provided in the member’s home or in a setting of his or her choice.

The services this plan covers are similar to Family Care and Home and Community-Based Waivers except that Family Care Partnership also covers acute and primary care services.

The Family Care Partnership is not yet available in all counties.

Family Care Partnership enrollment rules are similar to either Home and Community-Based Waivers or Institutional Medicaid, depending on your circumstances.

Spousal Impoverishment ProtectionsSpecial financial protections are allowed for the spouse and dependents of a long-term care member to keep assets and income that are above Medicaid financial limits.

Spousal Impoverishment Asset LimitFor long-term care cases where one spouse is still living in the community, special asset protection rules apply at the time of application.

Asset AssessmentAn asset assessment is done by your agency to establish the asset limit for your Medicaid long-term care (Institutional Medicaid, Home and Community-Based Waivers, or Family Care) application.

During the asset assessment, you will be required to provide proof of assets that you and your spouse owned on the date of the first continuous period of institutionalization that lasted 30 days or longer, or on the date of the initial request for Home and Community-Based Waivers, Family Care, or Family Care Partnership, whichever occurs earlier.

Based on the proof you provide, your agency will determine “the total countable assets of the couple” and the community spouse asset share.

The asset limit for an applicant is $2,000 plus the community spouse asset share. The community spouse asset share is the amount of countable assets above $2,000 that the community spouse or the institutionalized person, or both, can have at the time the institutionalized person wants to enroll in Medicaid long-term care. However, transfer of non-exempt assets or homestead property for less than fair market value by the community spouse within the first five years after the Medicaid member is found eligible is also considered divestment and will result in a divestment penalty for the Medicaid member.

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Once the spouse in the institution is enrolled, the assets of the community spouse are considered unavailable to the institutionalized spouse.

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Full Coverage Health Care Plans

The following are details of how the community asset share and asset limit are determined: If the total countable assets of the couple are

$252,840 or more, then the community spouse asset share is $126,420; the Medicaid long-term care asset limit at the time of application in long-term care is $128,420 ($126,420 + $2,000).

If the total countable assets of the couple are less than $252,840 but greater than $100,000, then the community spouse asset share is half of the total countable assets; the Medicaid long-term care asset limit is half of the total countable assets plus $2,000.

If the total countable assets of the couple are $100,000 or less, then the community spouse asset share is $50,000; the Medicaid long-term care asset limit is $52,000 ($50,000 + $2,000).

The institutional spouse cannot be enrolled in Medicaid long-term care as long as the total assets of the community spouse and institutionalized spouse are above the combined asset limit of $2,000 plus the community spouse asset share.

Excess assets (assets that are above the asset limit) can be reduced to allowable limits if they are used to pay for nursing home or home care costs, as well as other expenses, such as home repairs or improvements, vehicle repair or replacement, clothing, or other household expenses.

Spousal Impoverishment CalculationThe long-term care income limit is the same whether or not the institutionalized person has a spouse or any dependent relatives in the community. However, for an institutionalized person who does have a spouse in the community, the person applying for or enrolled in the long-term care program is allowed to give some of his or her income back to the community spouse and any dependent relatives living with the community spouse. This is referred to as an income allocation.

Community Spouse Income AllocationThe community spouse income allocation is calculated by subtracting the gross income of the community spouse from the maximum community spouse income allocation.

$ Maximum community spouse allocation- Gross income of community spouse= $ Community spouse income allocation

The maximum income allocation is the lesser of the following: The maximum community spouse income allocation

of $3,160.50 $2,743.34 plus excess shelter allowance

Community Spouse Excess Shelter AllowanceAs of July 1, 2019, the community spouse excess shelter allowance is any shelter expense over $845.50.

This amount may be updated each year (see Spousal Impoverishment Protections section on page 32).

Excess Shelter Allowance$ Rent

+ Mortgage (principal and interest)+ Property taxes+ Homeowners or renters insurance+ Condominium fee+ Standard utility amount= $ Total shelter expense- $845.50 (Amount as of July 1, 2019)= $ Excess shelter allowance

Maximum Community Spouse Income AllocationAs of January 1, 2018, the maximum community spouse income allocation is $3,160.50. This amount may be updated each year.

Dependent Relative Income AllocationThe dependent relative income allocation is calculated by subtracting the dependent family member’s income from the maximum dependent family member income allocation.

Maximum dependent family member income allocation ($704.58 as of July 1, 2019)

- Dependent family member’s income= $ Dependent relative income allocation

Family Maintenance Allowance (Home and Community-Based Waivers/Family Care)The family maintenance allowance is for the support of family members when spousal impoverishment protections do not apply. If the waiver member is a disabled child, the family maintenance allowance is not included.

When the waiver member is the custodial parent of minor children living in the home and there is no spouse in the home, the family maintenance allowance is calculated using the following steps:

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Full Coverage Health Care Plans

1. The minor children’s adjusted income is calculated by subtracting the 65 and One-Half Credit for Earned Income from the minor children’s gross earned income and then adding the minor children’s other income.

$ Minor children’s gross earned income- $65 and ½ Credit for Earned Income+ Minor children’s total other income= $ Minor children’s adjusted income

2. The minor children’s adjusted income is then compared to the Medicaid Level 1 income limit for the number of individuals in the household. (The waiver applicant is not included in the group size.)

Group Size Medicaid Level 1 Income Limit1 $591.672 $591.67

3. If the minor children’s adjusted income is greater than the Medicaid Level 1 income limit, there is no family maintenance allowance. If the minor children’s adjusted income is less than the Medicaid Level 1 income limit, the family maintenance allowance is the difference between the minor children’s adjusted income and the Medicaid Level 1 income limit.

$ Medicaid Level 1 income limit- Minor children’s adjusted income= $ Family maintenance allowance

SSI Payment Level Plus the E Supplement for One PersonThis amount is $950.77.

If the spouse’s adjusted income is greater than the SSI payment level plus the E supplement for one person, there is no family maintenance allowance.

If the spouse’s adjusted income is less than the SSI payment level plus the E supplement for one person, the family maintenance allowance is calculated as follows:

$950.77 SSI payment level plus the E supplement for one person

- Spouse’s adjusted income= $ Family maintenance allowance

DivestmentDivestment means to give away resources, such as income, non-exempt assets, and property, for less than

fair market value in order to be able to enroll in Medicaid long-term care services. Divestment can include giving gifts of cash or trips or establishing trusts for family members, whether they are adults or children. Fair market value is an estimate of the price an asset could have been sold for on the open market at the time it was given away or sold below value. Divestment is also an action taken to avoid receiving income or assets that you are entitled to receive.

Divesting financial resources within 60 months before your application for Medicaid long-term care services, or after you are enrolled, may result in a divestment penalty period.

Transfer of non-exempt assets or homestead property for less than fair market value by the community spouse within the first five years after the Medicaid member is found eligible is also considered divestment and will result in a divestment penalty for the Medicaid member.

Medicaid will not pay for long-term care benefits through Home and Community-Based Waivers, Institutional Medicaid, or Family Care plans during a divestment penalty period. The divestment penalty period is calculated as follows:

$ Divestment amount÷ Average nursing home daily rate

($287.29 as of July 1, 2019)= Length of the divestment penalty period

(in days)

ForwardHealth CardEach person enrolled in BadgerCare Plus or Medicaid will get a ForwardHealth card. You should keep your ForwardHealth card unless you are sent a new card or your agency tells you to throw it away. You will not get a new card each time you enroll in benefits unless you request a new one.

Your ForwardHealth card does not show the dates that you are enrolled. You will get an enrollment letter in the mail from your agency with your dates of enrollment.

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Full Coverage Health Care Plans

If there is an emergency and you do not have your card with you when you get services, give your ForwardHealth card number to all those who provided services as soon as possible.

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Limited Coverage Health Care Plans

Family Planning Only ServicesCertain individuals with income at or below 300% of the federal poverty level may be able to get Family Planning Only Services.

See the How Income is Counted section on page 19 to see how income is counted for Family Planning Only Services.

You can apply online at access.wisconsin.gov or by calling your agency.

To be eligible for the Family Planning Only Services Program, you must: Be a U.S. citizen or have a qualifying immigration

status. Be of childbearing or reproductive age. Have monthly income at or below 300% of the

federal poverty level. (Only your own income is counted; your assets are not counted.)

Not be enrolled in BadgerCare Plus or Medicaid. (You can be enrolled in private health insurance while you are enrolled in the Family Planning Only Services Program.)

NOTE: The following covered services could change. Ask your provider to see if the service you need is covered.

Through an initial or routine family planning-related office visit, the following services may be covered: Contraceptive services and supplies (birth control

supplies such as birth control pills, condoms, intrauterine devices)—you must have a prescription from a doctor or nurse practitioner

Natural family planning supplies Pap tests Routine preventative primary services that are

family planning-related Tests and treatment for sexually transmitted

diseases/infections like chlamydia, herpes, gonorrhea, and syphilis, as well as certain other lab tests

Tubal ligation for women or voluntary sterilizations for men 21 years old or older

NOTE: Only certain services are covered under the Family Planning Only Services Program. Services not covered include, but are not limited to, the following: Hysterectomies Inpatient hospital services Mammograms Vaccinations Other services provided during a family

planning-related visit that are not family planning-related

You should tell your health care provider you have this plan before you get services. Your provider must tell you if a service is not covered.

If a service is not covered and you still want and get the service, you will have to pay for it. You may also call the number on the back of your ForwardHealth card and ask if a service is covered.

This is a limited benefit plan. You may be able to enroll in the BadgerCare Plus plan, which is a full benefits plan. See the BadgerCare Plus section on page 19 for information on applying for BadgerCare Plus.

Federal law allows members to choose their provider, including physicians and family planning clinics, for family planning services and supplies. This means you can also go to any family planning clinic that will accept your ForwardHealth card, even if the clinic is not part of your HMO.

If you want more information or have questions, go to www.dhs.wisconsin.gov/forwardhealth/resources.htm or call Member Services at 800-362-3002.

Medicare Savings ProgramWisconsin Medicaid may be able to help pay for certain Medicare costs if you request and qualify for the Medicare Savings Program (also called Premium Assistance).

This program is for those who are eligible to take part in Medicare and who have low income and limited assets. The asset limits for the Medicare Savings Program are:

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Group Size Asset Limit1 $7,7302 $11,600

Not all of your income and assets will be counted when determining if you are able to enroll in the Medicare Savings Program. Income and asset limits may change each year. For current amounts, go to www.dhs.wisconsin.gov/forwardhealth/resources.htm or call Member Services at 800-362-3002.

Qualified Medicare Beneficiary (QMB)Medicaid will pay any Medicare Part A and B premiums, Medicare co-insurance, and Medicare deductibles if all of the following are true: You are entitled to Medicare Part A. You have assets at or below the program limit. You have monthly income at or below 100% of the

federal poverty level after subtracting certain credits.

Specified Low-Income Medicare BeneficiaryMedicaid will pay Medicare Part B premiums if all of the following are true: You are currently getting Medicare Part A. You have assets at or below the program limit. You have monthly income between 100% and 120%

of the federal poverty level after subtracting certain credits.

Specified Low-Income Medicare Beneficiary PlusThis program is also known as Qualifying Individual Group 1. Medicaid will pay your Medicare Part B premiums if all of the following are true: You are currently getting Medicare Part A. You have assets at or below the program limit. You are not enrolled in Medicaid. You have monthly income between 120% and 135%

of the federal poverty level after subtracting certain credits.

Qualified Disabled and Working IndividualThe asset limits for qualified disabled and working individuals are:

Group Size Asset Limit1 $4,0002 $6,000

Medicaid will pay for Part A premiums if all of the following are true: You have a disability. You are employed. You are entitled to Medicare Part A. You have assets at or below the program limit. You have monthly income less than 200% of the

federal poverty level after subtracting certain credits. You are not enrolled in Medicaid.

When Your Payments Will BeginIf you are enrolled in any of the Medicare Savings Program plans, it will take at least two months for payments to begin. This is the time that is needed for payments to be adjusted by Wisconsin Medicaid, Medicare, and the Social Security Administration.

When Medicaid starts paying your Medicare premiums, your Social Security check will increase. If payments do not begin right away, you may get a refund from the Social Security Administration.

Medicare Savings Program CalculationsYour counted income for the Medicare Savings Program is calculated as follows:

$ Earned income- $65 and ½ Credit for Earned Income+ Other income- Special Exempt Income Credit- $20 Standard Medicaid Credit= $ Counted income

SeniorCare Prescription Drug Assistance ProgramSeniorCare helps Wisconsin seniors with their prescription drug costs. To enroll in SeniorCare, you must: Be a Wisconsin resident. Be a U.S. citizen or have qualifying immigrant

status. Be 65 years of age or older. Pay a $30 annual enrollment fee per person.

Only certain income is counted for SeniorCare. Assets, such as bank accounts, insurance policies, and home property, are not counted.

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Coverage LevelsSeniorCare members are subject to certain annual out-of-pocket expenses and/or copays depending on their annual income. Drug coverage may vary by level of enrollment.

There are four levels of enrollment for SeniorCare based on income limits (as of February 1, 2019): Level 1: For those with annual income at or below

$19,984 (individual) or $27,056 (couple) Level 2a: For those with annual income of $19,985

to $24,980 (individual) or $27,057 to $33,820 (couple)

Level 2b: For those with annual income of $24,981 to $29,976 (individual) or $39,821 to $40,584 (couple)

Level 3: For those with annual income of $29,977 or higher (individual) or $40,585 or higher (couple)

NOTE: There is no asset limit for the SeniorCare program.

You can apply for SeniorCare by completing the SeniorCare Application (F-10076). To get an application or more information about SeniorCare, contact the SeniorCare Customer Service hotline at 800-657-2038 or go to www.dhs.wisconsin.gov/ forwardhealth/resources.htm .

SeniorCare CardEveryone who is enrolled in SeniorCare will get a SeniorCare card.

When going to a SeniorCare pharmacy provider, be sure to take your card with you. The SeniorCare card will be used to verify your enrollment at each visit.

If you have questions about your card, contact the SeniorCare Customer Service hotline at 800-657-2038.

Tuberculosis-Related MedicaidTuberculosis-Related Medicaid helps pay some medical costs for the care of tuberculosis (TB) infection or disease.

To get this benefit, a person must meet income and asset rules and have been infected with TB. For one person, the gross monthly income limit is $1,627 as of January 1, 2019. Starting September 1, 2019, there is also a gross monthly income limit of $2,399 for a married couple getting TB benefits. See the Income Rules and Limits on page20 through 25.

Tuberculosis-Related Medicaid only covers services directly related to the care of TB. These include: Physician services Prescription drugs Laboratory tests and x-rays Clinic services Services designed to encourage completion of

treatment Services needed due to side effects of prescribed

drugs for TB care

NOTE: Tuberculosis-Related Medicaid does not pay for hospital stays or room and board.

Emergency Services PlanThe Emergency Services Plan provides short-term coverage for people who have an emergency medical condition and meet all program rules except for their immigration status.

A medical emergency is a problem that could put your health at risk if you do not get medical care right away.

The Emergency Services Plan will only pay for health care you get for an emergency medical condition.

NOTE: The Emergency Services Plan does not guarantee that the care you get will be covered. You will have to pay the cost of health care you get if it is not considered an emergency.

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Important Information for All Health Care Plans

Deductible PlansYou may be able to enroll in a deductible plan if you are one of the following: A pregnant woman with income over 300% of the

federal poverty level A child under 19 years of age with income over

300% of the federal poverty level A child under 19 years of age with income over

150% of the federal poverty level and access to employer-sponsored health insurance where the employer pays 80% or more of the premium

An elderly or disabled adult with household income over the Medicaid limit ($591.67)

For children, the deductible is the difference between the family’s income and 150% of the federal poverty level over a six-month period. For pregnant women who are not applying for the BadgerCare Plus Prenatal Plan, the deductible is the difference between the family’s income and 300% of the federal poverty level over a six-month period.

When a family has medical expenses that add up to the deductible amount, the child or pregnant woman will be enrolled in BadgerCare Plus and will not have a premium. For the purpose of determining a deductible, family income includes the income of the individual, his or her spouse (if married), and his or her parents (if he or she is younger than 19). The income of siblings, tax dependents, and other family members is not included.

Limits for Emergency ServicesAll health care plans have limits on when you can use emergency room and ambulance services. These services can only be used in an emergency situation.

Emergencies are situations that require medical attention right away to prevent death or serious damage to your health. Nonemergencies are illnesses, injuries, or medical needs that are usually taken care of at a doctor’s office.

Examples of nonemergencies include the following: Needing a prescription refilled A minor cut or burn

A skin rash A sprain or strain Back pain A toothache Cold or flu symptoms A common headache Needing a checkup Needing a pregnancy test, medical test, or other lab

test Having an ongoing condition that has not suddenly

changed or worsened

Use of the emergency room or ambulance rides because it is easier for you to use these services will not be covered. To avoid using emergency rooms and ambulance services: Have a regular doctor. Keep your appointments. Call your doctor or nurse helpline about your

medical needs if one is available to you.

Prior Authorization for ServicesSome services must be approved before you can get them. This is called “prior authorization.”

Your provider asks for the approval for these services from ForwardHealth. If your provider does not get the services approved, ForwardHealth will not pay for the services. The provider will then be responsible for the cost of care provided. If you choose to get a service after you know the approval was denied, the provider can bill you for the service.

If You Get a BillForwardHealth pays your provider for covered services. A provider should not ask you, your family, or others to pay anything other than a copay for covered services. If you get something that looks like a bill, contact the provider who is billing you. Providers know the ForwardHealth coverage limits. The provider must tell you if ForwardHealth does not cover a service before the service is provided.

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Enrollment in a BadgerCare Plus or Medicaid Health Maintenance Organization (HMO)One of the many benefits of enrolling in BadgerCare Plus or Medicaid is that you and your family will also be enrolled in an HMO.

An HMO has a network of doctors, hospitals, and clinics that can work together to help you manage your health care.

Enrolling in an HMOOnce you are enrolled in BadgerCare Plus or Medicaid SSI, you will receive an HMO enrollment packet in the mail with information about the HMOs in your area and how to choose an HMO.

If there are two or more BadgerCare Plus HMOs where you live, you must enroll in an HMO, and you will have a choice of which HMO to enroll in. If you live in a rural area where there is only one BadgerCare Plus HMO, you must enroll in the HMO. If you live in a non-rural area where there is only one BadgerCare Plus HMO, you can choose whether to enroll in the HMO.

If there are two or more Medicaid SSI HMOs where you live, you must enroll in an HMO, and you will have a choice of which HMO to enroll in. If there is only one Medicaid SSI HMO where you live, you can choose whether to enroll in an HMO.

After enrolling in an HMO, you will get all your health care from providers who are contracted with your HMO. Your HMO will send you a member packet that lists the doctors, hospitals, and clinics you can use.

You may only get care from providers outside your HMO if: It is an emergency. Your HMO says you may see another doctor. The service is a Medicaid-covered service but is not

covered by your HMO (for example, dental or chiropractic services).

If you do not choose an HMO, one will be picked for you. After enrolling in an HMO, you have 90 days to change your mind and choose a different HMO.

Benefits of an HMOBetter Access to CareYour HMO’s job is to provide you with the care you need when you need it. Your HMO has a variety of doctors, specialists, clinics, and hospitals for you to choose from. Your HMO will support you and help you get appointments with doctors or specialists that could be hard for non-HMO members to get. HMOs make sure that you are able to see a primary care doctor within 30 days of when you call and a behavioral health provider within 30 days after an inpatient mental health stay.

If you have a doctor or provider that is not part of an HMO, your Medicaid SSI HMO will let you see that provider for 90 days after you enroll to continue your care.

If you currently have approval to get certain services under fee-for-service Medicaid, your Medicaid SSI HMO will let you continue to get those services from the same provider for 90 days after you enroll.

Personalized and Coordinated CareYour HMO has a care manager who will: Support you. Work with you to develop a care plan to make sure

you get the care you need. Help you schedule appointments with providers. Review doctor instructions with you. Help you with your medications. Follow up with you after a hospital stay or an

emergency room visit.

Your care manager can refer you to community resources to help with other issues that might impact your well-being, like housing, employment, legal help, food security, transportation, and child care.

Increased QualityYour HMO is required to provide you with all of the care you need while also meeting high standards of care. As part of the high-quality care HMOs provide, they will reach out to assess your health care needs so they can connect you to services, and they may provide reminders for important services you need.

Member SafeguardsIf you have problems getting health care services through your HMO, there are resources to help you. Resources include advocates at your HMO and at

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Disability Rights Wisconsin, an ombudsman, and an enrollment specialist.

Other ProvidersIf you are not enrolled in an HMO, you should check with your health care provider to see if your provider takes BadgerCare Plus and/or Medicaid. If not, call Member Services at 800-362-3002 and ask for help finding a provider who does take BadgerCare Plus and/or Medicaid. All services must be provided by your HMO or a BadgerCare Plus/Medicaid provider. If you get services from someone who is not, you will be responsible for paying the cost of the services.

If there is an emergency and you do not have your ForwardHealth card with you when you get services, give your ForwardHealth card number to all those who provided the services as soon as possible.

Report Your ChangesBadgerCare Plus and MedicaidFor both BadgerCare Plus and Medicaid, you must report the following changes to your agency within 10 days of the change: You have a change in where you live or where you

are staying, including Wisconsin residency. A homeless person living in Wisconsin must be physically present in Wisconsin.

Someone moves into or out of your home. Your household relationships change (someone gets

married, divorced, or adopted). Your family’s monthly income (before taxes) goes

over a certain monthly income limit for your family. Your enrollment letters (see the Letters About Your Benefits section on page 52) will give you the monthly income limit for your family size and the reporting rules.

For Medicaid, you must also report changes in your household’s assets or expenses.

For BadgerCare Plus, you must also report a change in: Expected tax filing status. Tax dependents. Tax deductions.

If you do not report a change and you get coverage when you should not, you may have to repay the cost of that coverage.

If you move out of Wisconsin and do not report this move, you will be required to repay any payments made

by ForwardHealth to your HMO or other health care providers, even if you did not use your ForwardHealth card. Temporary absence from Wisconsin ends when another state determines the person is a resident there for Medicaid or medical assistance purposes.

Example: BadgerCare Plus—If ForwardHealth paid your HMO $475 each month for your family, you would have to repay the State of Wisconsin $475 for each month the HMO was paid after you moved out of Wisconsin.

Example: Medicaid—In January, you were enrolled in Medicaid with a cost share of $200. When you enrolled, you were given a $75 credit for a health insurance expense. At the end of March, you cancelled the health insurance, but you did not report it until June. Your overpayment would be the difference between your new cost share and the old cost share for May and June.

Family Planning Only ServicesIf you are enrolled in Family Planning Only Services, changes in your income will not affect your enrollment until your next renewal. However, you must report the following changes to your agency within 10 days: You move to a new address. You move out of Wisconsin. Where you live changes (for example, you go to

prison or go into a nursing home or other institution).

Well Woman MedicaidIf you are enrolled in Well Woman Medicaid, you must report the following changes to your agency: You reach 65 years of age. Your address changes. You move out of Wisconsin. You receive Medicare Part A, Part B, or both. You no longer need treatment for breast or cervical

cancer. You enroll in private or other public insurance that

covers your cancer treatment.

How to Report ChangesYou can report changes in the following ways: Online at access.wisconsin.gov. By phone: Contact your agency to report changes. By mail or fax:

o For Medicaid or Caretaker Supplement, you can use the Medicaid Change Report (F-10137).

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o For BadgerCare Plus, Caretaker Supplement, and Family Planning Only Services, you can use the Information Change Report (F-10183).

To get these forms, go to www.dhs.wisconsin.gov/ forwardhealth/change-report.htm or contact your agency.

NOTE: If you receive SSI benefits, your changes should be reported to the Social Security Administration.

If you do not report a change, you may be required to pay for services you received after your cost share or enrollment status should have changed.

You may be required to give proof of some of these changes (see Appendix D: Examples of Proof on page 63).

Renew Your BenefitsOnce you are enrolled in BadgerCare Plus, Medicaid, or Family Planning Only Services, a renewal must be completed at least once each year. The renewal is to make sure you still meet all program rules and you are getting the correct benefits. If the renewal is not done, your benefits will end.

There are many ways to do a renewal. You can do your renewal online at access.wisconsin.gov, by phone, by mail, by fax, or in person. You will receive a letter in the mail the month before your renewal is due.

For example, if your renewal is due in April, your letter will be sent in March. This letter will also tell you how you can complete your renewal.

Monthly PremiumsBadgerCare Plus Premiums and CopaysChildren ages 1 through 18 enrolled in BadgerCare Plus with family income between 200% and 300% of the federal poverty level will be required to pay a premium.

The following individuals will not be required to pay a premium for BadgerCare: Tribal members and children and grandchildren of

tribal members Any members who are eligible to get Indian Health

Services

Pregnant women Adults who are blind or disabled, as determined by

the Disability Determination Bureau Former foster care youths Adults and children in a BadgerCare Plus extension*

*An extension is a period of enrollment given to a parent or caretaker when his or her income increases above 100% of the federal poverty level due to an increase in earned income or spousal support/alimony and he or she still meets all other program rules.

If you have a child who is required to pay a premium, his or her premium will be set at a specific amount depending on your family’s income and will not be more than 5% of your family’s counted income. If your child is required to pay a premium, the first payment must be paid to your agency before the child can enroll (see Appendix C: BadgerCare Plus Monthly Premiums on page 60 for more information on premium amounts).

Some services require you to pay part of the cost of care. This is called a copayment or copay. More information about copays is in Appendix B: Covered Services and Copays for BadgerCare Plus and Medicaid Programs on page 56.

Premium Payment MethodsIf you are required to pay a monthly premium, you will have choices on how you can pay your premium.

You may pay by check or money order, electronic funds transfer (EFT), or wage withholding. To learn more about your options or for help, contact the Premium Payment Unit at 888-907-4455.

Nonpayment of PremiumsIf you are required to pay a monthly premium for a child and you do not pay it, your child’s BadgerCare Plus benefits will end, and the child will not be able to get benefits for three months. However, if you pay any premiums owed, you can re-enroll your child during the three-month period. After three months, you can again enroll your child without paying any past premiums.

Other Health InsuranceIf you or anyone in your family has any other health insurance coverage, you must tell your agency. If you do not inform your agency about any other health insurance, your benefits may be denied or ended.

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Anyone requesting BadgerCare Plus is required to make an assignment of Medical Support Liability. Medical Support Liability means that applicants and members must sign over to the State of Wisconsin all rights to payments from court-ordered medical support or from other third-party payers of your medical expenses.

Examples of third-party payers are: Other health insurance plans (besides BadgerCare

Plus or Medicaid). Individuals or entities responsible for payments for

an accident or injury if BadgerCare Plus or Medicaid paid for any services due to the accident (see Accident and Injury Claims on page 45).

In some situations, you must cooperate with a child support agency to establish paternity for your child. This means that if you were not married at the time of your child’s birth, the child support agency will help you legally name the father.

If your child does not have health insurance and has an absent parent, you must help the child support agency to get insurance information from the absent parent.

The child support agency will also help you get and keep getting health insurance (medical support) for your child through court orders. You must cooperate with the child support agency unless any of the following are true: You are a pregnant woman. You are under age 18. You have good cause for not cooperating.

There are different good cause reasons. If you think you may have a good cause reason for not cooperating with the child support agency, tell your local agency.

If you have questions about your other insurance coverage, ask your insurance company. If you have questions or complaints regarding that insurance company, contact:

Office of the Commissioner of InsuranceBureau of Market RegulationPO Box 7873Madison, WI 53707-7873800-236-8517

Access to Affordable Employer-Sponsored Health InsuranceBadgerCare Plus provides health care coverage to pregnant women, children, parents, caretaker relatives, and adults with no dependent children living in the home. Pregnant women applying for BadgerCare Plus Prenatal Services and some children are not eligible for BadgerCare Plus if they have access to affordable employer-sponsored health insurance or access to the state employee health insurance plan through their employer unless they have a good cause for not signing up for the insurance. Employer-sponsored health insurance is considered affordable if the employer pays 80% or more of the cost of the premiums for a family plan covering major medical expenses.

Access to employer-sponsored health insurance means you or someone in your home is able, or has been able, to sign up for health insurance through an employer: Past access means you or someone in your home

was able to sign up for health insurance through a current employer in the last 12 months.

Current access means you or someone in your home can sign up for health insurance through an employer in the next three months.

The following individuals may be able to enroll in BadgerCare Plus, even if they have access to employer-sponsored health insurance: Newborns under 1 year old Children ages 1 to 5 years old with family income no

more than 185% of the federal poverty level Children ages 6 to 18 years old with family income

no more than 150% of the federal poverty level Former foster care youths leaving out-of-home care,

such as foster care People with a disability (must be determined by the

Disability Determination Bureau or the Social Security Administration)

Parents, caretaker relatives, or adults with no dependent children living in the home

Most pregnant women

Some good cause reasons may include: Your employer dropped all health insurance

coverage for all employees. You had a different type of health care coverage at

the time you could have enrolled in your employer’s health insurance plan.

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If you have a reason not listed above and you feel it should be considered, contact your agency.

Children who have access to employer-sponsored insurance may still be able to enroll in BadgerCare Plus by meeting a deductible. For more information about the deductible plans, see page 2.

Applying for BadgerCare Plus for Pregnant WomenIf you are a pregnant woman applying for BadgerCare Plus and you are a U.S. citizen or qualifying immigrant, you may be able to enroll, even if you have access to an employer-sponsored health insurance plan.

BadgerCare Plus Prenatal ServicesIf you are applying for prenatal services because of your immigration or citizenship status or you are in jail, you will not be able to enroll if: You have access to an employer-sponsored health

insurance plan in which the employer pays at least 80% of the premium.

You are covered by any other health insurance.

Accident and Injury ClaimsIf you are in an accident or are injured and you get a cash award or settlement due to the accident or injury and ForwardHealth paid for part or all of your care, you must report this to all of the following: Your local agency, The Wisconsin Casualty Recovery Unit, and Your HMO or managed care organization (MCO) if

you are enrolled in one.

When Medicaid pays for a claim that is related to an accident, a letter is sent to you telling you about the requirement to report the information.

If you have hired an attorney or are working with an insurance agency to settle your claim, you must also report this information to your agency, Wisconsin Casualty Recovery Unit, and your HMO or MCO.

You can contact Wisconsin Casualty Recovery Unit by phone, mail, fax, email, or online.

Wisconsin Casualty Recovery – HMS5615 Highpoint DriveIrving, TX 75038-9984Phone: 877-391-7471

Fax: 469-359-4319Email: wicasualty@hms.comOnline: www.wicasualty.com/wi/index.asp

When contacting Wisconsin Casualty Recovery Unit, provide your ForwardHealth ID number, the date of the accident, and the insurance company or name of the attorney, along with any claims.

Required Proof/Verification for FoodShare and Health CareYou may be required to provide proof of your answers for FoodShare, BadgerCare Plus, and Medicaid when applying for benefits, renewing benefits, or reporting changes. Appendix D: Examples of Proof on page 63 describes what items you can use to provide proof.

NOTE: If you need help getting any proof, contact your agency.

If you have already given proof of citizenship and identity to your agency in the past, you will not have to provide this information again.

You will not have to provide proof of citizenship or identity if you are: Currently getting Social Security Disability

Insurance. Currently getting SSI benefits. Currently receiving Medicare. Applying for or enrolled in the Emergency Services

Plan. Applying for or enrolled in the BadgerCare Plus

Prenatal Plan.

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Collection and Use of Information

The information required on your application, including the Social Security number of each household member applying for benefits, is authorized under the Food and Nutrition Act of 2008, as amended PL 110-246 (7 United States Code 2011-2036), and Wis. Stat. § 49.82(2). If you do not have a Social Security number due to religious beliefs or because of your immigration status, you will not be required to give a Social Security number.

The information will be used to determine if your household can get or keep getting benefits.

Information you give will be verified through computer matching programs. This information will also be used to monitor compliance with program rules and for program management.

This information may be given to other federal and state agencies for official examination. This information may also be given to law enforcement officials for the purpose of apprehending people fleeing to avoid the law if they are applying for or receiving FoodShare benefits.

Providing information on your application, including the Social Security number of each household member, is voluntary. However, any person who is asking for benefits (FoodShare, BadgerCare Plus, or Medicaid) but does not give a Social Security number will not be able to get benefits unless they meet one of the exceptions for Medicaid or BadgerCare Plus.

Exceptions include applicants applying for BadgerCare Plus Prenatal Plan or Emergency Services. Another exception is anyone who belongs to a recognized religious group that objects to persons being assigned a Social Security number.

Any Social Security number provided for members who are not enrolled will be used and disclosed in the same way as Social Security numbers of enrolled household members.

Your Social Security number will not be shared with United States Citizenship and Immigration Services. Your application for BadgerCare Plus or Medicaid is also an application for help with paying for private health insurance through the federal Health Insurance

Marketplace. If you do not meet the rules to enroll in BadgerCare Plus or Medicaid, your information will be sent to the Marketplace. If this happens, the Marketplace will contact you to let you know if you are able to get help with paying for private health insurance. To learn more about the Marketplace, visit healthcare.gov or call 800-318-2596 (voice) or 711 (TTY).

Ethnicity and Race information may be provided voluntarily by individuals but is not required to get benefits. This information is collected to ensure individuals are not discriminated against and to improve our programs.

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Non-Emergency Medical Transportation

The following information is about non-emergency medical transportation. If you have a medical emergency, you should call 911.

Non-emergency medical transportation is a public transportation and shared ride service. Rides can include public transportation (such as a city bus), rides in specialized medical vehicles, or rides in other types of vehicles depending on your medical and transportation needs. If public transportation is not available, you will not be required to take it.

Medical Transportation Management, Inc. (MTM, Inc.), is the transportation manager for BadgerCare Plus and Wisconsin Medicaid. MTM, Inc., schedules and pays for rides to BadgerCare Plus- and Medicaid-covered health care services.

You are able to get a ride to your BadgerCare Plus- or Medicaid-covered health care service if you have no other way to get to your appointment and you are enrolled in one of the following programs: BadgerCare Plus Wisconsin Medicaid (including IRIS) Family Planning Only Services Tuberculosis-Related Medicaid

If you are enrolled in Family Care, Family Care Partnership, or PACE, you will receive your rides through your managed care organization. If you reside in a nursing home, contact the nursing home regarding your transportation.

NOTE: MTM, Inc., is required to follow federal and state law and can only schedule and pay for rides if you are not able to get a free ride.

Mileage Reimbursement (Gas Payment)If you have a car and are able to drive yourself to your appointment but cannot afford to pay for gas, you may be able to be reimbursed for gas. Contact MTM, Inc., before you go to your appointment to see if you can be reimbursed for mileage.

Meals and LodgingYou may be able to get help paying for meals and overnight stays. BadgerCare Plus and Wisconsin Medicaid have rules for when members can get payment for meals and overnight stays when traveling by non-emergency medical transportation to BadgerCare Plus- and Medicaid-covered services.

Schedule a RideYou must schedule routine rides at least two business days before your appointment. You can schedule a routine ride by calling 866-907-1493 (voice) or 711 (TTY) Monday through Friday from 7 a.m. until 6 p.m. or online at www.mtm-inc.net/wisconsin/.

If you do not schedule a routine ride two business days before an appointment, you may not be able to get a ride, and you will need to reschedule your appointment. Holidays and weekends are not counted as business days. Business days include the day that you schedule the appointment but not the day of your appointment.

NOTE: MTM, Inc., is only able to pay for rides for BadgerCare Plus or Medicaid members and one adult if the member is a child or provides documentation of needing assistance.

When you call to schedule a ride, you should have the following information available: Your name, home address, and phone number Your ForwardHealth member number (which is the

10 numbers listed on your ForwardHealth card) The street address and phone number of where you

want to be picked up The name, phone number, address, and zip code of

the health care provider you are seeing The date and start time of your appointment The end time of your appointment if you know it Any special ride needs, including if you need

someone to ride with you General reason for the appointment (for example,

checkup or eye appointment)

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NOTE: MTM, Inc., can also provide transportation to urgent appointments within three hours. Verification may be required.

For more information about scheduling rides; meals and lodging; new rules; or complaints, denied transportation, or fair hearings: Contact MTM, Inc., at 866-907-1493 (voice), 711

(TTY), or www.mtm-inc.net/wisconsin. Go to www.dhs.wisconsin.gov/nemt/index.htm . Call Member Services at 800-362-3002.

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Other Programs

Caretaker Supplement This program is a cash benefit for parents who are eligible for SSI payments and who are living with and caring for their minor children. The Caretaker Supplement benefit amounts are $250 per month for the first eligible child and $150 per month for each additional eligible child.

For more information, go to www.dhs.wisconsin.gov/ ssi/caretaker.htm.

WIC (Women, Infants, and Children Program)Young children and pregnant women may be able to get WIC, a special supplemental food program for women, infants, and children. This program provides nutritious food and nutrition and health counseling.

To find out more about WIC and other programs, go to www.dhs.wisconsin.gov/wic/index.htm or access.wisconsin.gov or call 800-722-2295.

Job Center of WisconsinJob Center of Wisconsin is available to you. Job Center is the largest source of job openings in Wisconsin. Visit the Job Center website at jobcenterofwisconsin.com or you can use touchscreen computers at your local job center.

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Your Rights

When applying for or getting FoodShare, BadgerCare Plus, Wisconsin Medicaid, or Family Planning Only Services, you have the right to: Be treated with respect by agency staff. Have your civil rights upheld. To learn more, see the

Nondiscrimination section on page 53. Have your private information kept private. Get an application or have an application mailed on

the same day you ask for it. Have an application accepted right away by your

agency. Ask your agency to explain anything in this

handbook you do not understand. Get a decision about your application within 30 days

of the day your agency gets your application.

NOTE: If your agency gets your application (online or on paper) after 4:30 p.m. on a weekday or on a weekend or holiday, the date of receipt will be the next business day.

Get FoodShare benefits within seven days of applying if you are in immediate need and qualify for faster service.

Be told in advance if your benefits are going to be reduced or ended and the reason for the change.

Ask for a fair hearing if you do not agree with any action of your agency.

See agency records and files relating to you, except information obtained from a confidential source.

Fair HearingsAny time your benefits are denied, reduced, or ended and you think your agency made a mistake, contact the agency.

If the agency does not agree, you can ask the agency worker to help you in asking for a prehearing conference and a fair hearing.

Prehearing ConferenceYou may be able to come to an agreement with the agency through a prehearing conference without having to wait for a fair hearing to take place. At a conference, you get to tell your side of the story.

Your agency will explain why the action was taken. If the agency finds that it has made a mistake, it will change its decision and take corrective action. If the agency decides that its initial decision is correct and you still feel the agency is wrong, you have the right to go through the fair hearing process.

NOTE: Agreeing to have a prehearing conference does not affect your right to have a fair hearing. You can ask for a fair hearing, and if you are satisfied with the action of the prehearing conference, you can cancel your fair hearing.

Fair HearingA fair hearing gives you the chance to tell a hearing officer why you think the decision about your application or benefits was wrong. At the hearing, a hearing officer will hear from you and the agency to find out if the decision was right or wrong. You may bring a friend or family member with you to the hearing. You may also be able to get free legal help. See the Legal Help section on page 52 to learn more.

When to Use the Fair Hearing ProcessExamples of when to ask for a fair hearing include the following: You believe your application was denied unfairly or

in error. Your benefits were suspended, reduced, or ended

and you think it was a mistake. You do not agree with the amount of benefits you

are getting. Your application was not acted on within 30 days.

Read each letter you get carefully to help you understand the action taken. If the reason for the change in your benefits is a federal or state rule change, the Division of Hearings and Appeals is not required to give you a fair hearing.

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Your Rights

How to Ask for a Fair HearingAsk your agency to help you file for a fair hearing, or write directly to:

Department of AdministrationDivision of Hearings and AppealsPO Box 7875Madison, WI 53707-7875

You can get the Fair Hearing Request form online at www.dhs.wisconsin.gov/forwardhealth/resources.htm or by calling 608-266-7709.

If you choose to write a letter in place of the form, you must include the following: Your name Your mailing address A brief description of the problem The name of the agency that took the action or

denied the service Your Social Security number Your signature

For FoodShare, your agency can take your request verbally.

For health care, a request for a fair hearing must be made no later than 45 days after the date of the action being appealed. For FoodShare, a request must be made no later than 90 days after the date of the action being appealed. You can request a hearing at any time while you are getting FoodShare benefits if you do not agree with the benefit amount. Your latest enrollment letter will have the date by which you must request a hearing.

You, your chosen representative (if you have one), and your agency will get written notice at least 10 days before the hearing with the time, date, and place of the hearing.

Preparing for a Fair HearingYou have the right to bring witnesses, your own lawyer, or another advisor to the fair hearing. The Department of Health Services will not pay for legal help to represent you, but they may be able to help you find free legal help for questions or fair hearing representation.

You have the right to review any information in your case file that was used to determine your enrollment.

You or your representative has the right to: Question anyone who testifies at the fair hearing. Present your own arguments and written materials

that show why you think you are right.

If the fair hearing is about whether or not you are disabled or unable to work due to illness or injury, you have the right to present medical evidence for proof. Your agency will pay for the cost of the medical evidence.

If you cannot speak English, you have the right to have an interpreter present at the hearing. The Division of Hearings and Appeals may pay for translation or interpreters if you ask.

Continuation of BenefitsIf you are getting benefits and you ask for a hearing before your benefits change, you can keep getting the same benefits until the hearing officer makes a decision.

If the hearing officer decides that your agency was right, you may need to return or repay the extra benefits that you got between the time you asked for your fair hearing and the time that the hearing officer decides about your case.

If you have asked for a fair hearing, you will still need to complete any scheduled renewals. If your agency tells you before the fair hearing has taken place that your enrollment period has ended, you must reapply and meet all program rules for your benefits to be continued. If the renewal shows that there have been changes in your circumstances, your benefits may change or end because of these changes.

Effects of the Fair HearingIf the fair hearing decision is in your favor, no action will be taken against you by the agency. If your benefits have been ended, you will start receiving them again. The date you will start getting benefits will be listed in the letter of the fair hearing decision you get.

If the fair hearing is decided against you, the action will stand, and you will have to pay back any benefits you should not have received. Ask your agency about any limitations on the recovery of overpayments.

No other action will be taken against you for filing a fair hearing request.

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Your Rights

RehearingIf you do not agree with the fair hearing decision, you have the right to ask for a rehearing if you: Have new evidence that was not known or available

to you before the hearing that could change the decision.

Feel that there was a mistake in the facts of the decision.

Feel that there was a mistake in the legal basis of the decision.

A written request for a rehearing must be received within 20 days after the date of the written decision from the fair hearing. The Division of Hearings and Appeals will then decide within 30 days of getting the written request if you will get a rehearing. If the agency does not issue a written response to your request within 30 days, your request is denied.

Appealing a Hearing or Rehearing DecisionIf you do not agree with the fair hearing or rehearing decision, it is still possible for you to appeal this decision to the circuit court in your county. This must be done within 30 days after you get the written decision about the fair hearing or within 30 days of the denial of the rehearing request. An appeal to the circuit court must be done by filing a petition with the clerk of courts in your county. It is best to have legal help if you decide to appeal a fair hearing decision in circuit court.

Legal HelpYou may be able to get legal help from Wisconsin Judicare, Inc., or Legal Action of Wisconsin, Inc. (LAW). To find the office closest to you: Call Judicare at 800-472-1638 or go to

www.judicare.org. Call LAW at 888-278-0633 or go to

www.badgerlaw.net.

Letters About Your BenefitsYou will get letters about your benefits. These letters tell you the status of your benefits.

A letter will be sent to you before any change in your FoodShare or health care benefits. It is important that you read each letter you get.

These letters will tell you if: Your benefits are being reduced or ending. Your agency is waiting for anything from you. You need to do a renewal to keep getting benefits.

You can choose to get your letters online instead of by regular mail. To make this choice, log in to your ACCESS account at access.wisconsin.gov. If you do not have an ACCESS account, you can create one to view your letters and information about your benefits online.

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Nondiscrimination

Nondiscrimination NoticeDiscrimination is Against the Law – Health Care-Related ProgramsThe Wisconsin Department of Health Services complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Department of Health Services does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

The Department of Health Services: Provides free aids and services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreters.o Written information in other formats (large print, audio, accessible electronic formats, other formats).

Provides free language services to people whose primary language is not English, such as:o Qualified interpreters.o Information written in other languages.

If you need these services, contact the Department of Health Services civil rights coordinator at 844-201-6870.

If you believe that the Department of Health Services has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Department of Health Services, Attn: Civil Rights Coordinator, 1 West Wilson Street, Room 651, PO Box 7850, Madison, WI 53707-7850, 844-201-6870, TTY: 711, Fax: 608-267-1434, or email to dhscrc@dhs.wisconsin.gov. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Department of Health Services civil rights coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 20201 800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Español (Spanish) Deitsch (Pennsylvania Dutch)ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 844-201-6870 (TTY: 711).

Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 844-201-6870 (TTY: 711).

Hmoob (Hmong) ພາສາລາວ (Laotian)LUS CEEV:  Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 844-201-6870 (TTY: 711).

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 844-201-6870 (TTY: 711).

繁體中文 (Chinese) Français (French)注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 844-201-6870 (TTY: 711).

ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.  Appelez le 844-201-6870 (ATS: 711).

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Deutsch (German) Polski (Polish)ACHTUNG:  Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 844-201-6870 (TTY: 711).

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 844-201-6870 (TTY: 711).

(Arabic) العربية हि�ंदी (Hindi)اللغوية: المساعدة خدمات فإن اللغة، اذكر تتحدث كنت إذا ملحوظة

. برقم اتصل بالمجان لك الصم ( 6870-201-844تتوافر هاتف رقم.)711والبكم:

ध्यान दें: यदिद आप हि�ंदी बोलते �ैं तो आपके लिलए मुफ्त में भाषा स�ायता सेवाए ंउपलब्ध �ैं। 844-201-6870 (TTY: 711) पर कॉल करें।

Русский (Russian) Shqip (Albanian)ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 844-201-6870 (телетайп: 711).

KUJDES:  Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 844-201-6870 (TTY: 711).

한국어 (Korean) Tagalog (Tagalog – Filipino)주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 844-201-6870 (TTY: 711) 번으로 전화해 주십시오.

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USDA Nondiscrimination StatementIn accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: How to File a Complaint, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights1400 Independence Avenue, SWWashington, D.C. 20250-9410;

(2) fax: (202) 690-7442; or

(3) email: program.intake@usda.gov.

This institution is an equal opportunity provider.

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Appendix A: Program Income LimitsProgram income limits are based on federal guidelines, which may change each year. For current guidelines, go to www.dhs.wisconsin.gov/forwardhealth/resources.htm or call 800-362-3002.

FoodShare Monthly Income Limits/Maximum Benefit Amounts—Effective October 1, 2019

People in Household

Gross Monthly Income Limit at 200% FPL

Gross Monthly Income Limit at

130% FPL

Gross Monthly Income Limit

at 100% FPLMaximum Benefit

Amount1 $2,082 $1,354 $1,041 $1942 $2,820 $1,832 $1,410 $3553 $3,556 $2,311 $1,778 $5094 $4,292 $2,790 $2,146 $6465 $5,030 $3,269 $2,515 $7686 $5,766 $3,748 $2,883 $9217 $6,502 $4,227 $3,251 $1,0188 $7,240 $4,705 $3,620 $1,164

For each additional person add:$738 $479 $369 $146

Health Care Monthly Income Limits—Effective February 1, 2019Group Size 100% FPL 120% FPL 135% FPL 150% FPL 200% FPL 250% FPL 300% FPL

1 $1,040.83 $1,249.00 $1,405.12 $1,561.25 $2,081.66 $2,602.08 $3,122.492 $1,409.17 $1,691.00 $1,902.38 $2,113.76 $2,818.34 $3,522.93 $4,227.513 $1,777.50 $2,133.00 $2,399.63 $2,666.25 $3,555.00 $4,443.75 $5,332.504 $2,145.83 $2,575.00 $2,896.87 $3,218.75 $4,291.66 $5,364.58 $6,437.495 $2,514.17 $3,017.00 $3,394.13 $3,771.26 $5,028.34 $6,285.43 $7,542.516 $2,882.50 $3,459.00 $3,891.38 $4,323.75 $5,765.00 $7,206.25 $8,647.507 $3,250.83 $3,901.00 $4,388.62 $4,876.25 $6,501.66 $8,127.08 $9,752.498 $3,619.17 $4,343.00 $4,885.88 $5,428.76 $7,238.34 $9,047.93 $10,857.51

For each additional person, add:$368.33 $442.00 $497.25 $552.50 $736.66 $920.83 $1,104.99

*See page 22, Income Deductions and Disregards, for more information about pretax and tax deductions.FPL=federal poverty level

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Appendix B: Covered Services and Copays for BadgerCare Plus and

Medicaid Programs

Covered Services and CopaysYou may be required to pay a part of the cost of a BadgerCare Plus- or Medicaid-covered service. This payment is called a copay. The table on the following pages lists what services are covered and what the copays are for those services. The table also indicates if you are exempt from copays.

You will not be required to make a copayment for any BadgerCare Plus or Medicaid-covered service if you or your child is in one of the following groups (all others may be required to pay, depending on the service received): Children in foster care, regardless of age Children in adoption assistance, regardless of age Children younger than age 1 with household income

up to 150 percent of the federal poverty level Children ages 1 through 5 with household income up

to 185 percent of the federal poverty level Children ages 6 through 18 with household incomes

at or below 133 percent of the federal poverty level Children in the Katie Beckett Program, regardless of

age Children who are American Indian or Alaska

Natives at any income level American Indians or Alaska Natives, regardless of

age or income level, who are receiving or have ever received items and services either directly from an Indian health care provider or through referral under contract health services

Terminally ill individuals receiving hospice care Nursing home residents Members enrolled in Wisconsin Well Woman

Medicaid Individuals eligible through Express Enrollment Children younger than age 18 who are in SSI or an

SSI-related eligibility group BadgerCare Plus parents and caretakers and

childless adults with no reportable income

Providers are required to make a reasonable effort to collect the copay but cannot refuse services to a member who fails to make that payment.

NOTE: Because covered services and copays could change, you should ask your provider what your copay amount will be. If you get more than one service during the same appointment, you may be asked for more than one copay.

Example: If you saw your doctor and you also had an x-ray, you would have two copays: one for the doctor’s visit and one for the x-ray.

A provider can charge you for services that are not covered by BadgerCare Plus or Wisconsin Medicaid if both of the following are true: The provider told you before providing the service

that the service was not covered. You agreed to pay for the service.

NOTE: To make sure your BadgerCare Plus- or Medicaid-covered prescriptions are paid for, your prescribing provider and your pharmacy must both be Medicaid-enrolled. If not, you may be required to pay for these prescriptions.

Out-of-State ClaimsEmergenciesIf you travel outside of Wisconsin and need emergency services, health care providers can treat you and send claims to BadgerCare Plus or Wisconsin Medicaid. You will have to pay for any service you get outside Wisconsin if the health care provider refuses to submit claims or refuses to accept Badger Care Plus or Medicaid payment as payment in full.

NonemergenciesIf you need to see a provider outside Wisconsin for nonemergency services, that health care provider may need to request approval (see the Prior Authorization for Services section on page 40).

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Services Not Covered Under Any PlanServices or items not covered include (but are not limited to) the following: Services that needed approval (prior authorization)

before you got them Items such as televisions, radios, air conditioners,

and exercise equipment (even if prescribed by a physician)

Procedures considered experimental or cosmetic in nature

HealthCheckHealthCheck is a preventive health checkup plan for anyone under the age of 21 who is currently enrolled in BadgerCare Plus or Wisconsin Medicaid.

HealthCheck providers will teach you and any children you have how to lower the risk of serious illness and help find health problems early, before they get worse.

HealthCheck meets the physical exam rules for Head Start; Child Care; the Woman, Infants and Children (WIC) program; and school physicals. Your child may also be able to get certain services not normally paid for by BadgerCare Plus or Wisconsin Medicaid by getting a HealthCheck exam.

Call Member Services at 800-362-3002 to find your HealthCheck provider. If you are enrolled in a BadgerCare Plus or Medicaid HMO, call the HMO for information on HealthCheck services.

Page | 57

Appendix B: Covered Services and Copays for BadgerCare Plus and Medicaid Programs

Table of Covered Services and CopaysCovered Services and Copays for BadgerCare Plus, Medicaid, and Wisconsin Well Woman Medicaid

Ambulatory Surgical Centers

Coverage of certain surgical procedures and related lab services—$3 copay per service.

Behavioral Treatment

Full coverage of comprehensive and focused behavioral treatment services (with prior authorization). No copay.

Chiropractic Services

Full coverage—$0.50 to $3 copay per service.

Dental Services

Full coverage—$0.50 to $3 copay per service.

Disposable Medical Supplies (DMS)

Full coverage—$0.50 to $3 copay per service and $0.50 per prescription for diabetic supplies.

Drugs (Prescription)

Coverage of generic and brand name prescription drugs and some over-the-counter (OTC) drugs.

Copay:

$0.50 for over-the-counter drugs $1 for generic drugs $3 for brand

Copays are limited to $12 per member, per provider, per month. Over-the-counter drugs do not count toward the $12 maximum.

Limit of five opioid prescription fills per month.

Durable Medical Equipment (DME)

Full coverage—$0.50 to $3 copay per item. Rental items are not subject to copay.

End-Stage Renal Disease (ESRD)

Full coverage. No copay.

HealthCheck Screenings for Children

Full coverage of HealthCheck screenings and other services for individuals under 21 years of age. No copay.

Hearing Services

Full coverage—$0.50 to $3 copay per procedure. No copay for hearing aid batteries.

Home Care Services (Home Health, Private Duty Nursing and Personal Care)

Full coverage of private duty nursing, home health services, and personal care. No copay.

Hospice

Full coverage. No copay.

Hospital Services: Inpatient

Full coverage—$3 copay per day with a $75 cap per stay.

Hospital: Outpatient

Full coverage—$3 copay per visit.

Hospital Services: Outpatient Emergency Room

Full coverage. No copay.

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Appendix B: Covered Services and Copays for BadgerCare Plus and Medicaid Programs

Covered Services and Copays for BadgerCare Plus, Medicaid, and Wisconsin Well Woman Medicaid

Mental Health and Substance Abuse Treatment

Full coverage (not including room and board).

$0.50 to $3 copay per service, limited to the first 15 hours or $825 of services, whichever comes first, provided per calendar year.Copays are not required when services are provided in a hospital setting.

Nursing Home Services

Full coverage. No copay.

Physician Services

Full coverage, including laboratory and radiology.$0.50 to $3 copay per service, limited to $30 per provider per calendar year.No copay for emergency services, preventive services, anesthesia, or clozapine management.

Podiatry Services

Full coverage—$0.50 to $3 copay per service; limited to $30 per provider per calendar year.

Prenatal/Maternity Care

Full coverage, including prenatal care coordination and preventive mental health and substance abuse screening and counseling for women at risk of mental health or substance abuse problems. This includes services provided by nurse midwives and licensed midwives. No copay.

Reproductive Health Services: Family Planning Services

Full coverage with the exceptions listed below. No copay for services provided by a family planning clinic or contraceptive management. Does not cover:

Reversal of voluntary sterilization Infertility treatments Surrogate parenting and related services, including, but not limited to:

o Artificial inseminationo Obstetrical careo Labor or deliveryo Prescription or over-the-counter drugs

Routine Vision

Full coverage, including eyeglasses—$0.50 to $3 copay per service. No copay for eyeglasses selected from the Medicaid collection.

Therapy: Physical Therapy, Occupational Therapy, and Speech and Language Pathology

Full coverage—$0.50 to $3 copay per service. Copay obligation limited to the first 30 hours or $1,500, whichever occurs first, during one calendar year (copay limits calculated separately for each discipline).

Transportation: Ambulance, Specialized Medical Vehicle, Common Carrier

Full coverage of emergency and non-emergency transportation to and from a certified provider for a BadgerCare Plus-covered service.

$2 copay for non-emergency ambulance trips. $1 copay per trip for transportation by specialized medical vehicle. No copay for transportation by common carrier or emergency ambulance.

Page | 59

Appendix C: BadgerCare Plus and Medicaid Purchase Plan Monthly

PremiumsBadgerCare Plus monthly premiums are based on family size, income, and federal poverty level guidelines. If you have a child (age 1 through 18) with family income over 200% of the federal poverty level, you will be required to pay a premium for that child unless the child is exempt from paying. To see what percentage of the federal poverty level your family’s income is at, see Appendix A: Program Income Limits on page 55.

Paying Your PremiumIf your household has a premium, you will get a BadgerCare Plus Premium slip each month.

You should mail your premium to the address on the slip. If you do not have your slip, write your case number on your check or money order and mail your premium to the following address:

BadgerCare Plusc/o Wisconsin Department of Health ServicesPO Box 6648Madison, WI 53716-0648

If you are required to pay a BadgerCare Plus monthly premium for your child and you do not pay it, your child’s BadgerCare Plus benefits will end, and your child will not be able to get benefits for three months. However, if you pay the premiums owed before the three months have passed, you can re-enroll your child during the three-month period. After three months, you can re-enroll your child without paying any past premiums.

Children Children will only pay a monthly premium if they are age 1 or older, have income over 201% of the federal poverty level, and are not any of the following: Pregnant Eligible for a deductible A tribal member Son or daughter of a tribal member Grandson or granddaughter of a tribal member Eligible to receive Indian Health Services

The tables on the next page tell you if a child: Will be required to pay a monthly premium and how

much the premium is. Will have copays. Can get backdated coverage.

Appendix C: BadgerCare Plus and Medicaid Purchase Plan Monthly Premiums

Monthly Premium TablesEnrollment InformationThe table below lists which children will have copays and premiums and who can get backdated coverage.

Income Limit(Amounts are on page 55) Children Under Age 1 Children Ages 1 Through 5 Children Ages 6 Through 18

At or below 133% FPL Premium: No

Copay: NoBackdated Coverage: Yes

Premium: No

Copay: NoBackdated Coverage: Yes

Premium: No

Copay: NoBackdated Coverage: Yes

From 133% to 150% FPL Premium: No

Copay: NoBackdated Coverage: Yes

Premium: No

Copay: NoBackdated Coverage: Yes

Premium: No

Copay: YesBackdated Coverage: Yes

From 150% to 185% FPL Premium: No

Copay: YesBackdated Coverage: Yes

Premium: No

Copay: NoBackdated Coverage: Yes

Premium: No

Copay: Yes**Backdated Coverage: No*

From 185% to 201% FPL Premium: No

Copay: YesBackdated Coverage: Yes

Premium: No

Copay: Yes**Backdated Coverage: No*

Premium: No

Copay: Yes**Backdated Coverage: No*

From 201% to 300% FPL Premium: No

Copay: YesBackdated Coverage: Yes

Premium: Yes**

Copay: Yes**Backdated Coverage: No*

Premium: Yes**

Copay: Yes**Backdated Coverage: No*

*Backdated coverage is available if the child meets a deductible.**Excludes children who are tribal members.FPL=federal poverty level

BadgerCare Plus Monthly Premiums for Children—current as of February 1, 2019

Family IncomeFrom

201% to 231% FPL

From 231% to

241% FPL

From 241% to

251% FPL

From 251% to

261% FPL

From 261% to

271% FPL

From 271% to

281% FPL

From 281% to

291% FPL

From 291% to

301% FPL

At or over 301% FPL

Monthly Premium Amount for Each Child $10 $15 $23 $34 $44 $55 $68 $82 $97.53

FPL=federal poverty level

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Appendix C: BadgerCare Plus and Medicaid Purchase Plan Monthly Premiums

Medicaid Purchase Plan Premium TableNet Monthly Income Amount

PremiumNet Monthly Income Amount

PremiumFrom To From To$0.00 $25.00 $0.00 $500.01 $525.00 $500.00

$25.01 $50.00 $25.00 $525.01 $550.00 $525.00$50.01 $75.00 $50.00 $550.01 $575.00 $550.00$75.01 $100.00 $75.00 $575.01 $600.00 $575.00

$100.01 $125.00 $100.00 $600.01 $625.00 $600.00$125.01 $150.00 $125.00 $625.01 $650.00 $625.00$150.01 $175.00 $150.00 $650.01 $675.00 $650.00$175.01 $200.00 $175.00 $675.01 $700.00 $675.00$200.01 $225.00 $200.00 $700.01 $725.00 $700.00$225.01 $250.00 $225.00 $725.01 $750.00 $725.00$250.01 $275.00 $250.00 $750.01 $775.00 $750.00$275.01 $300.00 $275.00 $775.01 $800.00 $775.00$300.01 $325.00 $300.00 $800.01 $825.00 $800.00$325.01 $350.00 $325.00 $825.01 $850.00 $825.00$350.01 $375.00 $350.00 $850.01 $875.00 $850.00$375.01 $400.00 $375.00 $875.01 $900.00 $875.00$400.01 $425.00 $400.00 $900.01 $925.00 $900.00$425.01 $450.00 $425.00 $925.01 $950.00 $925.00$450.01 $475.00 $450.00 $950.01 $975.00 $950.00$475.01 $500.00 $475.00 $975.01 $1,000.00 $975.00

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Appendix D: Examples of ProofWhen you apply for or renew benefits or report a change, you may have to provide additional information or proof. The following is a list of examples of proof. In some cases, your agency can get proof from other sources, and you will not have to provide it. If you need help getting proof, call your agency.

Proof of Disability Approval letter from the state Disability Determination Bureau Award letter from the Social Security Administration

Proof of Identity Valid U.S. passport Valid state driver’s license or state identity card School picture ID Employee photo ID Military dependent ID card Military ID or draft record Native American tribal enrollment document For children under 18 applying for BadgerCare Plus or Medicaid, a signed Statement of Identity form, F-10154 (You can

contact your agency for this form.) United States Citizenship and Immigration Services (USCIS) photo ID

Other/Additional Proof of Identity – FoodShare Only Birth certificate Hospital birth record Adoption record Paycheck or wage stubs Completed Application for a Social Security Card, SS-5 Confirmation or church membership papers Voter registration card Family records (birthday books, genealogy, newspaper birth announcement, marriage license, support or divorce papers) Life insurance policy Other social services program ID Labor union or fraternal organization records Court order of name change

Other/Additional Proof of Identity – FoodShare and Health CareMedical records (vaccination certificate, doctor’s or clinic’s records, bills)

Proof of U.S. Citizenship for Adults and Children Valid U.S. passport Certified copy of U.S. birth certificate Citizenship ID card Certificate of Citizenship or Naturalization Adoption papers Military, hospital, school, insurance, or nursing home record showing a U.S. birthplace Native American ID card or other document issued by a federally recognized tribe

Proof of Immigration Status (if you are not a U.S. citizen) Permanent resident or “green” card Certificate of Naturalization Any documents issued by USCIS, an alien registration number (“A”), or other USCIS number

Proof of Tribal Membership and/or Native American or Alaska Native Descent Tribal enrollment card Written verification or document issued by the tribe indicating tribal affiliation Certificate of Degree of Indian Blood issued by the Bureau of Indian Affairs Tribal census document Medical record card or similar documentation issued by an Indian caregiver that specifies Indian descent

Appendix D: Examples of Proof

Proof of Able-Bodied Adult Exemptions Medical Exemption from Work Requirement for Able-Bodied Adults Without Dependents form, F-01598 Statement from health care, social worker, or alcohol and other drug abuse professional Statement of disability from employer or private disability agency Collateral contact Other acceptable written statement

Proof of Child Support and/or Alimony Paid or Received Court order Payment record from other state

Proof of Assets Bank statements Titles Contracts Deeds Financial records Life insurance policies

Proof of Job Income Check stubs (for the last 30 days) An Employer Verification of Earnings (EVF-E) form, F-10146 (You can contact your agency for this form. Your employer

must complete and sign the form. Return the completed form to the address on the form.) A letter from the employer (If you choose a letter, it must have the same information as the EVF-E form.)

Proof of Self-Employment Income Copies of tax forms A Self-Employment Income Report form, F-00107 (You can contact your agency for this form. This form should only be

used if you have not yet filed taxes for your self-employment business.)

Proof of Other IncomeNote: Some examples of other income are alimony, child support, disability or sick pay, interest or dividends, veterans benefits, workers compensation, and unemployment insurance. Pension statement Copy of current check Unemployment Compensation award letter Divorce documents showing financial settlement, maintenance, family support, or child support Documentation of court-awarded settlement Social Security award letter Veterans Affairs award letter Compensation award letter Financial aid award letter Tax records showing unearned income Documentation from any other source of income Proof of a Kinship Care, Foster Care, or Subsidized Guardian payment or interim caretaker payment (may be verbal or

written confirmation from the child protective services agency)

Proof of Wisconsin Residency Lease, rental agreement, or receipt or letter from landlord with current address Mortgage receipt with current address Utility and/or phone bill with current address Check stubs with name, current address, and employer Subsidized housing program approval document Weatherization program approval document Current state of Wisconsin driver’s license Current Wisconsin ID card Current motor vehicle registrationNote: Homeless individuals and families do not have to provide verification for their home address but must certify that they live in Wisconsin and plan to continue to live in Wisconsin.

Page | 64

Appendix D: Examples of Proof

Proof of Education School schedule Report card

Proof of Medical Costs Billing statement or itemized receipts Medicare card showing Part B coverage Health insurance policy showing premium, coinsurance, copayment, or deductible Medicine or pill bottle with price on label

Proof of Pretax Deductions Check stubs A letter from the employer

Proof of Tax Deductions Receipts Bank statements Check stubs Previous years’ tax forms

Proof of Not Being Able to Care for Child and Participate in Approved ActivityLetter from a physician, psychiatrist, or psychologist declaring the parent is unable to care for children and unable to participate in an approved activity

Proof of Child Care Costs Written statement from child care provider Cancelled check Paid receipt or bill

Proof of Shelter and/or Utility Expenses Mortgage payment records Rent receipt Statement from landlord Lease U.S. Department of Housing and Urban Development (HUD) subsidized housing approval Property tax statement Utility bill Statement from utility company Phone bill Homeowner's insurance policy or billing statement WHEAP/LIHEAP or other energy assistance

Division of Medicaid ServicesP-00079 (11/2019)

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STATE OF WISCONSINDEPARTMENT OF HEALTH SERVICESPO BOX 309MADISON WI 53701-0309

PRSRT STDU.S. POSTAGE

PAIDMadison, WI

Permit No 1369